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Hibrarp 


ANEMIA    AND 
RESUSCITATION 


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ANEMIA    AND 
RESUSCITATION 

AN  EXPERIMENTAL  AND 
CLINICAL    RESEARCH 


BY 

GEORGE   W.  CRILE 

PROFESSOR   OF   SURGERY,  WESTERN   RESERVE   UNIVERSITY   MEDICAL   COLLEGE; 
SURGEON   TO   LAKESIDE  HOSPITAL,    CLEVELAND,    OHIO. 


NEW  YORK  AND  LONDON 
D.    APPLETON    AND    COMPANY 

1914 


Copyright,  1914,  by 
D.  APPLETON  AND   COMPANY 


)u- If    ' 


Printed  in  the  United  States  of  America 


TO 
HOWARD    MELVILLE    HANNA,    ESQ. 

WHO   IN   HIS    GENEROUS    DEVOTION  TO    THE    WELFARE    OF   HIS    FELLOWMEN 

HAS    FOSTERED    MEDICAL   RESEARCH 

BY   WISE     COUNCILS     AND     LARGE     GIFTS 

IS   DEDICATED 

ALL  THAT  IS  OF  VALUE  IN  THE  RESEARCHES 
RECORDED  IN  THIS  WORK 


PREFACE 

In  presenting  the  material  of  this  book  for  publication 
it  gives  me  pleasure  to  express  my  many  obligations  to  my 
associates.  Although  the  problems  originated  in  my  clinic, 
and  the  experiments  were  planned  by  me,  their  accomplish- 
ment was  made  possible  by  the  diligent  labors  of  my  asso- 
ciates. Part  of  the  subject  matter  was  presented  before  the 
College  of  Physicians,  Philadelphia,  in  1908  as  the  Mutter 
Lecture  for  that  year  under  the  title  "Surgical  Anemia  and 
Resuscitation." 

To  Dr.  D.  H.  Dolley's  untiring  efforts,  for  which  appre- 
ciation has  already  been  expressed  in  "Hemorrhage  and  Trans- 
fusion," is  due  the  large  accumulation  of  data  on  cerebral 
anemia. 

In  the  research  on  anemia  of  the  voluntary  muscles  I  am 
indebted  for  the  preliminary  work  to  Dr.  Lawrence  Pomeroy, 
and  for  the  later  work  to  Dr.  A.  M.  Tweedie.  The  research  on 
anemia  of  the  intestines  was  also  in  charge  of  Dr.  Tweedie,  Dr. 
H.  G.  Sloan  conducting  the  experiments  on  certain  phases  of 
this  important  work.  The  neurocytologic  work  in  this  research, 
as  well  as  some  of  the  later  work  on  cerebral  anemia,  was  done 
by  Dr.  J.  B.  Austin.  The  drawings  illustrating  the  changes 
in  the  brain  cells  in  gangrene  of  the  intestine  were  made  by 
Miss  Armenouhie  H.  Tashjian. 

vii 


viii  PREFACE 

To  Dr.  Charles  S.  White,  of  Washington,  D.  C,  are  due 
my  thanks  for  permission  to  use  the  three  illustrations  showing 
the  relationship  of  the  thoracic  viscera,  and  also  to  "Surgery, 
Gynecology,  and  Obstetrics"  for  the  blocks  for  the  same. 

To  Dr.  F.  W.  Hitchings  I  wish  to  express  my  especial  ap- 
preciation for  his  tireless  labor  and  enthusiasm  in  the  arduous 
task  of  compiling  the  various  tables,  abstracting  the  literature, 
arranging  the  experimental  data,  and  assembling  all  of  the 
material  into  book  form. 

The  final  revision  of  the  text  was  made  by  my  editor,  Miss 
Amy  Rowland. 

G.  W.  C. 


CONTENTS 


PAGE 

INTRODUCTION 3 


CHAPTER  I 

ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM.     EXPERI- 
MENTAL   OBSERVATIONS 5-54 

Introductiox 5 

The  Blood  Supply  of  the  Brain  :  General  Considera- 
tions   6 

The  General  Effects  of  Complete  Anemia  of  the  Cen- 
tral Nervous  System  as  Seen  in  Dogs  Resuscitated 

after  Relative  Death 8 

Technique  of  Experiments lo 

Recovery  Results 13 

Special  Phenomena  following  Resuscitation         .        .       20 
Comparison  of  the  Author's  Results  with  the  Results 

of  Others 28 

Summary 30 

Protocols  of  Ten  Selected  Experiments        ...       31 
Table      I — Time  of  the  Respiratory  and  Circulatory 

Changes 50 

Table     II — Ten  Cases   in  Which  the  Total  xA.nemia 

Lasted  Seven  and  One-Half  or  More  Minutes       .  ■     51 
Table  III — The  Course  of  the  Blood-Pressure  after 

Resuscitation 52 

Table  IV — The  Time  of  Return  of  the  Reflexes  after 

Restoration   of  the  Circulation 53 

Conclusions 53 

ix 


CONTENTS 


CHAPTER  II 

PAGE 

ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM: 
CLINICAL  OBSERVATIONS.  CEREBRAL  ANEMIA 
THROUGH  LIGATION  OF  THE  COMMON  CAROTID 
ARTERIES       . 55-72 

General  Considerations 55 

Analysis  from  the  Literature  of  Five  Hundred  Cases 

OF  Ligation  of  the  Common  Carotid  Artery       .        .       57 
The    Author's    Cases    of    Temporary    Simultaneous 
Closure  of  Both  Common  Carotid  Arteries       .        .       64 
Technique  of  Ligation  of  the  Common  Carotid  Artery 

AND  Its  Branches 65 

Summary 72 

CHAPTER  III 

ANEMIA  OF  VOLUNTARY  MUSCLES:  EXPERIMENTAL 
OBSERVATIONS— ANEMIA  OF  THE  POSTERIOR  EX- 
TREMITY OF  DOGS 73-107 

Protocols  of  Forty-Three  Experiments       ....       75 

Conclusions 105 

Table — The  Results  Obtained  by  Causing  Anemia  of 
the  Hind  Legs  of  Dogs  for  Varied  Durations  of 
Time 106 

CHAPTER  IV 

ANEMIA  OF  VOLUNTARY  MUSCLES  :  CLINICAL  OBSERVA- 
TIONS—OCCLUSION OF  THE  ABDOMINAL  AORTA  IN 
MAN 108-122 

CHAPTER  V 

ANEMIA  OF  VOLUNTARY  MUSCLES  :  CLINICAL  OBSERVA- 
TIONS—ANEMIA OF  THE  LOWER  EXTREMITIES  IN 
MAN  THROUGH  LIGATION  OF  THE  MAIN  ARTERIAL 
TRUNKS        . 123-13^ 

Ligation  of  the  Common  Iliac  Artery 125 

Ligation  of  the  External  Iliac  Artery       ....     126 


CONTENTS  XI 

PAGE 

Ligation  of  the  Common  Femoral  Artery  ....  127 
Ligation  of  the  External  Femoral  Artery  .  .  .  130 
General  Recapitulation 132 


CHAPTER  VI 

ANEMIA  OF  VOLUNTARY  MUSCLES  :  CLINICAL  OBSERVA- 
TIONS—ISCHEMIC  PARALYSIS 133-143 

Case  in  Which  Pressure  on  the  Muscles  Apparently 
Played  an  Important  Part I33 

Case  in  Which  Embolism  of  the  Brachial  Artery  Was 
the  Only  Etiologic  Factor I35 

Case  in  Which  Marked  Muscular  Contracture  Fol- 
lowed Contusion  of  the  Leg;  Spontaneous  Re- 
covery          130 

Case  of  Ischemic  Contracture  in  Which  Pressure  Was 
Probably  an  Important  Etiologic  Factor  but  in 
Which  Marked  Relief  Followed  Freeing  of  Nerve 
Trunks  from  Pressure  by  Cicatricial  Tissue  .         .     140 

Case  in  Which  Bandaging  for  Uncomplicated  Pott's 
Fracture  Was  Followed  by  Gangrene,  Necessitat- 
ing Amputation 141 

-  Case  in   Which   Beginning  Gangrene  of  the  Hand 

Followed  Prolonged  Application  of  a  Tight  Sleeve     142 

Conclusions ^42 


CHAPTER  VII 

CERTAIN  CLINICAL  APPLICATIONS  FROM  THE  FOUR 
PREVIOUS  CHAPTERS.  LOCAL  GANGRENE  FROM 
ANEMIA  OF  THE  EXTERNAL  SOFT  PARTS  OF  THE 
BODY      . 144-149 

Anemia  in  Lesions  of  the  Spinal  Cord      ....     140 

Saline  Infusions ;       .       .       .       .     148 

Flap  Tension  and  Suture  Tension I49 


xii  CONTENTS 


CHAPTER  VIII 

PAGE 

ANEMIA  OF  THE  SMALL  INTESTINE:  EXPERIMENTAL 
OBSERVATIONS.  INTERFERENCE  WITH  THE  CIR- 
CULATION OF  LOOPS  OF  SMALL  INTESTINE  OF 
DOGS  FOR  DIFFERENT  LENGTHS  OF  TIME  UNDER 
DIFFERENT    CONDITIONS i5o-i94 

Experiments  in  Which  a  Loop  of  Small  Intestine 
■with  Its  Blood  Vessels  Was  Ligated  en  Masse  with 
Tape,  the  Tape  being  Removed  Before  the  Abdo- 
men Was   Closed 152 

Experiments  in  Which  a  Loop  of  Small  Intestine 
Was  Ligated,  a  Lateral  Anastomosis  Having  Been 
Previously  ^vlade  to  Isolate  the  Loop,  and  the  Tape 
Removed  Before  Closing  the  Abdomen  .         .         .     162 

Experiments  in  Which  a  Lateral  Anastomosis  Was 
Made,  a  Loop  of  Intestine  Ligated,  and  the  Tape 
Left  in  Place  After  the  Abdomen  Was  Closed       .     164 

Experiments  in  Which  a  Lateral  Anastomosis  Was 
Made,  a  Loop  of  Intestine  Ligated,  and  the  Loop 
Excised  at  the  End  of  the  Period  of  Anemia  Be- 
fore Closing  the  Abdomen 166 

Experiments  in  Which  a  Lateral  Anastomosis  Was 
Made,  a  Loop  of  Intestine  Ligated,  a  Drainage 
Tube  Inserted  Into  the  Loop,  and  the  Abdomen 
Closed 168 

Experiments  in  Which  a  Lateral  Anastomosis  Was 
Made,  a  Loop  of  Intestine  Ligated,  and  the  Loop 
Allowed  to  Project  Through  the  Abdominal 
Wound -.        .     172 

Experiments  in  Which  There  Was  Partial  Occlusion 
of  the  Blood-Supply  of  a  Loop  of  Intestine  by 
Ligation  of  the  Corresponding  Arteries  and  Veins, 
in  the  ^Mesentery 174 

Control  Experiment 176 

Tabulation  of  the  Experiments  on  Intestinal  Anemia     177 
Summary  of  Experiments  on  Intestinal  Anemia  .        .     178 


CONTENTS  Xiii 

PAGE 

The  Injection  into  the  Intestinal  Tract  and  Perito-     • 
NEAL  Cavity  of  Dogs  of  Juice  from  Loops  of  Small 
Intestine  Previously  Rendered  Ischemic  for  Vary- 
ing Periods  of  Time 179 

Injection  into  the  Peritoneal  Cavity     ....     180 
Injection  into  the  Lumen  of  the  Intestine     .        .        .     183 

Injection    Intravenously 186 

Injection  Intraperitoneally  of  Intestinal  Juice  from  a 

Dead  Dog 188 

Injection  of  Sterilized  Intestinal  Extract  (i)  Intra- 
venously and   (2)    Intraperitoneally   ....      189 
Injection  into  Dogs  of  Intestinal  Extract  from  Gan- 
grenous Intestine  of  Dogs,  or  of  Extract  from  In- 
testine of  Dead  Dogs 190 

Conclusions 193 

CHAPTER  IX 
ANEMIA    OF    THE    KIDNEYS    AND    SPLEEN        .        .       195-219 

Anemia  of  the  Kidneys 195 

Experiments  in  Which  the  Renal  Artery  Alone  Was 

Clamped 199 

Experiments  in  Which  Both  the  Renal  Artery  and 

Renal  Vein  Were  Clamped 207 

Anemia  of  the  Kidney  of  Dogs  from  Which  One 

Kidney  Had  Previously  Been  Removed  .       .        .211 

Summary  of  All   Experiments 212 

Conclusions 214 

Anemia  of  the  Spleen 214 

CHAPTER  X 
RESUSCITATION  OF  THE  BODY  AS  A  WHOLE    .        .       220-240 

General  Considerations 220 

Resuscitation  of  the  Respiratory  Apparatus  .       .       .  221 

Artificial  Respiration 221 

Schafer's  Table  Showing  the  Relative  Efficiency  of 

Methods  of  Giving  Artificial  Respiration  .        .        .  223 

Resuscitation  of  the  Circulatory  Apparatus  .       .       .  226 

Methods  Commonly  in  Use 226 


XIV  CONTENTS 

CHAPTER  XI 

PAGE 

RESUSCITATION    OF    THE    BODY    AS    A    WHOLE    (Con- 
tinued)             241-249 

The  Author's  Method  of  Resuscitation     ....     244 

CHAPTER  XII 

GENERAL  RECAPITULATION        .        .        .        .        .        .       250-251 

Local  Anemia 250 

Resuscitation 251 

BIBLIOGRAPHY      ..... 253 

APPENDIX 258 

INDEX 299 


LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

I.     Normal  Small  Intestine  of  a  Dog   (high  magnifica- 
tion)          151 

II.  Normal  Small  Intestine  of  a  Dog  (low  magnifica- 
tion)          151. 

III.  Anemia  of  the  Intestine.     Duration  of  anemia  four 

hours    (high  magnification) 157 

IV.  Anemia  of  the  Intestine.     Duration  of  anemia   four 

hours    (low   magnification) 157 

V.     Anemia  of  the  Intestine.     Duration  of  anemia  six 

hours    (high  magnification) 160 

VI.     Anemia  of  the   Intestine.     Duration  of  anemia   six 

hours    (low   magnification) 160 

VII.  Cortex  from  Normal  Dog.  Brain  cell  changes  pro- 
duced by  toxemia  due  to  anemia  of  the  small  intes- 
tines of  a  dog.    Facing  page 190 

VIII.  Cortex  from  Toxemic  Dog.  Brain  cell  changes  pro- 
duced by  toxemia  due  to  anemia  of  the  small  intes- 
tines of  a  dog.    Facing  page 190 

IX.  Cerebellum  from  Normal  Dog.  Brain  cell  changes 
produced  by  toxemia  due  to  anemia  of  the  small  in- 
testines of  a  dog.    Facing  page  ....  .     192 

X.  Cerebellum  From  Toxemic  Dog,  Brain  cell  changes 
produced  by  toxemia  due  to  anemia  of  the  small  in- 
testines of  a  dog.     Facing  page 192 

XI.     Anemia   of  the  Kidney.     Duration  of   anemia  seven 

hours    (low  magnification) 206 

XII.     Anemia   of  the  Kidney.     Duration   of   anemia   eight 

hours   (low  magnification)      .         .       -.         .         .         .     206 

XV 


xvi  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

XIII.  Longitudinal  Frozen  Section^  Showing  Relation  of 

THE  Heart  to  the  Diaphragm 235 

XIV.  The  Thoracic  Viscera  as  Seen  from  the  Front^  the 

Ribs  and  the  Sternum  Intact  .....     236 

XV.  The  Thoracic  Viscera  as  Seen  from  the  Front^  the 
Viscera  Being  Exposed  by  Removal  of  the  Ribs  and 
Sternum 237 

XVI,     Method  of   Giving  Adrenalin   by   Injecting   it   Di- 
rectly INTO  A  Stream  of  Normal  Saline  Solution    244 


SURGICAL   ANEMIA  AND 
RESUSCITATION 


INTRODUCTION 

The  following  studies  of  anemia  as  it  affects  the  body  as  a 
whole  or  its  component  parts  have  been  made  in  an  endeavor 
to  solve  practical  clinical  problems  which  both  the  surgeon  and 
the  internist  often  confront. 

In  regard  to  the  resuscitation  of  the  body  as  a  whole,  the 
fact  has  not  been  sufficiently  appreciated  that  the  greatest  and 
most  essential  difficulty  is  to  overcome  the  anemia  of  the 
brain.  In  apparent  death  from  drowning,  from  gas  poison- 
ing, from  electric  shock,  or  from  any  of  the  many  other  causes 
of  suspended  animation,  the  organ  which  most  quickly  suc- 
cumbs beyond  the  power  of  reanimation  is  the  brain  rather 
than  the  heart.  Since  continued  normal  action  of  the  heart 
and  lungs  is  dependent  on  the  activity  of  the  brain,  the  pres- 
ence or  absence,  as  well  as  the  degree  and  duration  of  anemia 
of  the  latter  organ,  decides  the  possibility  of  resuscitation. 

The  field  for  the  study  of  local  anemia  is  very  large. 
Among  the  commonest  examples  of  causes  of  local  anemia 
may  be  mentioned  embolism  and  thrombosis,  the  too  tight 
application  of  bandages  and  other  apparatus,  localized  pressure 
from  the  weight  of  the  body  in  unconscious  patients,  twisted 
pedicles  of  tumors  and  organs,  too  tight  packing  of  wounds, 
and  incarcerations  and  strangulations  of  intestines.  New 
problems  in  local  anemia  have  been  presented  in  the  last  few 
years,  largely  through  the  work  of  Carrel  in  transplanting 
organs  or  even  extremities  from  one  individual  to  another. 
Successful  organ  transplantation  presupposes  knowledge  of 

3 


4  INTRODUCTION 

the  power  of  any  given  organ  to  resist  anemia  while  the  opera- 
tion is  being  performed. 

KuHabko's  brilliant  work  in  making  the  heart  continue  to 
beat  after  its  removal  from  the  body,  supplemented  by  the 
work  of  Hill,  Batelli,  d'Halluin,  and  others  abroad,  and  of 
Stewart  and  his  associates  in  this  country,  paved  the  way 
to  further  study  of  the  automaticity  of  action  of  that  organ. 
Attempts  to  resuscitate  the  body  as  a  whole  by  massage  of 
the  heart,  by  artificial  respiration,  or  by  the  injection  of  saline 
or  other  solutions  into  the  circulation  were  the  natural 
sequence  of  their  results. 

The  experiments  from  the  author's  laboratory  which  are 
presented  in  this  book  are  a  continuation  of  those  on  surgical 
shock,  in  which  it  was  shown  for  the  first  time  that  the  blood 
pressure  of  a  decapitated  dog  could  be  maintained  for  hours 
by  means  of  the  slow,  continuous  infusion  of  normal  saline 
solution  and  adrenalin.  This  again  led  naturally  to  the  use 
of  the  adrenalin-saline  intravascular  infusion  combined  with 
rhythmic  pressure  on  the  chest  as  a  means  of  resuscitation,  a 
method  which,  so  far  as  is  known,  was  first  demonstrated  by 
the  author  before  the  Cleveland  Medical  Society  at  Western 
Reserve  University  Medical  College. 

In  this  monograph,  as  in  some  of  those  already  published, 
it  has  seemed  best  to  publish  the  experiments  in  considerable 
detail.  The  labor  and  expense  of  producing  them  have  been 
great,  and  their  publication  may  save  other  workers  unneces- 
sary repetition. 


CHAPTER  I 

ANEMIA  OF  THE   CENTRAL  NERVOUS   SYSTEM.      EXPERIMENTAL 

OBSERVATIONS. 

INTRODUCTION 

For  a  number  of  eminently  practical  as  well  as  scientific 
reasons  it  is  important  to  know  the  effects  of  total  or  par- 
tial anemia  of  the  brain.  For  example,  in  the  course  of 
operation  or  as  the  result  of  injury  the  surgeon  may  be  com- 
pelled to  choose  between  ligating  the  common  carotid  artery 
or  taking  other  hazards.  It  would  assist  him  in  making  an 
intelligent  decision  if  he  knew  the  effect  of  anemia  of  the 
brain.  In  operating  on  the  brain  he  may  be  obliged  to  retract 
a  portion  of  it,  thus  causing  localized  anemia.  How  long  will 
the  brain  safely  endure  such  anemia?  What  will  be  the  im- 
mediate and  final  results  if  he  resorts  to  these  measures? 
Will  intermittent  retraction  be  safe,  when  continuous  retrac- 
tion would  be  certain  to  cause  injury  from  local  anemia?  In 
cases  of  cerebral  compression  from  fracture  of  the  skull,  from 
tumors,  from  abscesses,  from  edema  of  the  brain,  from  hem- 
orrhage, anemia  is  in  many  instances  the  most  important 
factor. 

It  would  be  of  considerable  practical  value  to  know  whether 
or  not  all  parts  of  the  brain  and  spinal  cord  endure  anemia 
equally  well.  Do  differences  exist  between  the  resistance  of 
the  lower  and  higher  centers,  and  if  there  are  differences,  are 
they  because  the  one  has  been  established  earlier  in  the  course 

5 


6  SURGICAL  ANEMIA  AND  RESUSCITATION 

of  evolution  than  the  other,  and  has  become,  as  some  one  has 
expressed  it,  hardened  by  longer  use,  or  is  it  because  some  por- 
tions of  the  brain  are  more  delicately  poised  ?  Which  will  en- 
dure anemia  longer,  the  sight  or  the  auditory  mechanism,  an 
eye  reflex  or  a  tendon  reflex,  the  emotional  or  the  motor 
mechanism?  Will  a  given  amount  of  anemia  abolish  the 
memory  and  yet  leave  the  motor  mechanism  intact?  Among 
the  medullary  centers  is  the  respiratory  or  the  vasomotor,  the 
cardio-accelerator  or  the  cardio-inhibitory  the  more  resistant 
to  anemia? 

In  the  following  pages  an  attempt  has  been  made  to  throw 
light  on  these  various  questions.  The  importance  and  the 
difficulty  of  the  subject  must  be  the  excuse  for  presenting  so 
large  a  mass  of  data  in  detail  as  well  as  in  summary. 

THE  BLOOD  SUPPLY  OF  THE  BRAIN:  GENERAL 
CONSIDERATIONS 

In  the  course  of  evolution,  the  brain,  more  than  any  other 
organ  in  the  body,  has  been  evolved  in  such  a  way  as  to  have 
a  constant  supply  of  blood  under  even  pressure.  The  brain 
can  expand  but  the  skull  cannot  expand  under  the  influence 
of  increased  blood-pressure.  Consequently,  unless  there  were 
a  protective  mechanism  which  would  afford  a  constant  margin 
of  safety  against  over-expansion,  cerebral  anemia  due  to  pres- 
sure of  the  brain  against  the  skull  would  be  produced.  Such 
a  mechanism  is  provided  by  the  water-bed  of  cerebral  fluid  on 
which  the  brain  rests,  and  by  the  large  venous  sinuses. 

When  the  brain  expands  or  when  it  shrinks  in  volume  the 
cerebral  fluid,  which  connects  directly  with  the  spinal  fluid, 
ebbs  and  flows.  At  the  same  time  the  blood  in  the  large 
venous  sinuses  is  forced  out  or  in.  Under  ordinary  conditions 
this  prevents  undue  pressure  on  the  brain,  but,  as  a  protection 
against  cerebral  anemia,  another  mechanism  has  been  evolved, 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  7 

viz.,  the  elevation  of  the  arterial  blood-pressure  through  stim- 
ulation of  the  vasomotor  mechanism  by  anemia. 

Aside  from  the  volume  factor  of  safety,  the  importance 
of  the  brain  being  abundantly  supplied  with  blood  is  empha- 
sized by  the  provision  of  a  large  artery,  the  common  carotid, 
on  each  side  of  the  neck.  Moreover,  each  artery  is  well  pro- 
tected by  being  deeply  buried  under  strong  muscles  and  fasciae, 
and  is  so  placed  as  to  be  easily  defended  in  case  of  attack  on 
the  individual.  In  addition  to  the  great  carotids  there  are 
also  the  vertebral  arteries,  which  could  scarcely  be  torn  except 
by  such  an  injury  as  would  sever  the  head  from  the  body. 
A  still  further  addition  to  this  quadruple  supply  is  the  small 
amount  which  passes  through  the  arteries  of  the  spinal  cord. 

Besides  such  adequate  protection  against  cerebral  ane- 
mia, provision  for  equalization  of  intracerebral  pressure  is 
necessary.  This  is  secured  by  that  wonderful  adaptive  arrange- 
ment at  the  base  of  the  brain,  the  circle  of  Willis,  by  means  of 
which  blood  is  simultaneously  received  and  delivered  from  the 
above-mentioned  sources.  Under  normal  circumstances  the 
distribution  is  under  even  pressure  although  the  halves  of  the 
brain  may  not  receive  exactly  the  same  amounts  of  blood. 
Under  certain  other  circumstances,  however,  such  as  fighting, 
in  unusual  exertion  of  one  part  of  the  body,  in  certain  posi- 
tions of  the  neck  and  head,  and  when  one  side  of  the  neck  is 
subjected  to  direct  pressure,  there  may  be  inequality  of  pres- 
sure in  the  supplying  arteries,  but,  subject  to  the  laws  of 
physics,  the  inequality  must  be  largely  eliminated  in  the  circle 
of  Willis  and  hence  in  the  brain.  The  fact  that  cerebral  ar- 
teries are  straight  and  numerous  and  do  not  anastomose  freely 
has  an  important  and  direct  bearing.  Closure  of  an  artery 
between  the  heart  and  the  circle  of  Willis  is  a  very  different 
matter  from  closure  of  one  between  the  circle  of  Willis  and 
the  cerebral  tissue. 


8  SURGICAL  ANEMIA  AND  RESUSCITATION 

To  summarize  the  anatomical  points  which  have  a  direct 
bearing  on  cerebral  anemia :  ( i )  Provision  is  made  for  cere- 
bral expansion  and  contraction  within  the  skull;  (2)  there  is 
a  blood-pressure-raising  mechanism  with  which  to  combat 
anemia;  (3)  the  four  major  arteries  are  placed  in  the  most 
favorable  positions  for  both  active  and  passive  protection 
against  injury;  (4)  these  arteries  empty  into  a  circular  receiv- 
ing vessel  at  the  base  of  the  brain  which  equalizes  the  pressure 
and  from  which  an  even  start  is  made  for  the  passage  of  the 
blood  through  the  straight  non-anastomosing  arterial  trees 
to  every  part  of  the  cerebral  tissue. 


THE    GENERAL   EFFECTS    OF    COMPLETE   ANEMIA    OF 
THE  CENTRAL  NERVOUS  SYSTEM  AS  SEEN  IN  DOGS 
RESUSCITATED   AFTER  RELATIVE   DEATH 

The  method  employed  by  the  majority  of  investigators 
has  been  that  of  occlusion,  either  of  the  cerebral  vessels  or  of 
the  aorta  at  various  levels.  The  objection  to  this  method, 
which  is  frankly  acknowledged,  is  that  the  factor  of  collateral 
circulation  cannot  be  entirely  eliminated,  even  in  the  most 
favorable  animal,  the  cat.  Further,  the  brain  and  the  spinal 
cord  have  been  investigated  separately,  a  procedure  which 
must  make  a  vast  difference,  not  in  determining  the  relative 
viability  of  the  various  centers,  but  in  fixing  the  limit  of 
anemia,  admitting  of  a  complete  recovery  of  the  animal. 
Stewart  says  :  "Division  of  the  cord  in  the  upper  dorsal  region 
(III  to  VI  dorsal  vertebrae),  if  done  before  fairly  complete 
recovery  of  the  cerebral  centers,  is  followed  by  collapse,  dila- 
tation of  the  pupil,  cessation  of  respiration,  cardiac  failure, 
and  death.  The  integrity  of  the  spinal  centers  is  necessary  for 
the  resuscitation  of  the  cerebral  centers." 

Other  methods  of  investigation  employed,  such  as  artifi- 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  9 

cial  circulation  through  the  decapitated  head,  and  the  introduc- 
tion of  emboH,  preclude  the  possibility  of  recovery  studies. 
Within  the  last  decade,  with  the  more  or  less  successful  at- 
tempts at  resuscitation  of  the  heart,  contributions  to  the  sub- 
ject of  anemia  of  the  whole  central  nervous  system  have  been 
made  by  several  observers,  notably  Prus  and  Batelli. 

The  author's  study  of  brain  anemia  was  the  sequence  of 
work  on  the  resuscitation  of  animals  killed  by  anesthetics  and 
asphyxia,  which  may  be  briefly  summarized  as  follows :  By 
means  of  a  centripetal  infusion  of  salt  solution  into  an  artery 
together  with  the  simultaneous  injection  into  the  stream  of  one 
or  two  cubic  centimeters  of  1-1,000  adrenalin  chlorid,  the 
simultaneous  employment  of  vigorous  artificial  respiration 
and  rhythmic  pressure  on  the  thorax  over  the  heart,  the 
animal  may,  within  certain  limits,  be  resuscitated.  For  as 
long  as  five  minutes  after  total  cessation  of  function  resusci- 
tation is  usually  successful;  for  as  long  as  from  five  to  ten 
minutes  there  are  more  failures;  while  after  ten  minutes  the 
chances  of  success  are  progressively  less.  As  will  be  seen 
later,  this  method  is  uniformly  successful  within  the  limits 
which  are  compatible  with  viability  of  the  central  nervous  sys- 
tem. The  method  is  necessarily  self-limited,  for,  in  the  case 
of  a  heart  which  is  losing  its  irritability  owing  to  lapse  of 
time,  dilatation  may  occur  from  the  infusion  before  the  beat 
is  inaugurated.  Even  in  dogs  with  rigid  chest  walls  compres- 
sion of  the  chest  has  proved  satisfactory.  In  periods  under  five 
minutes  but  little  compression  is  necessary.  Direct  cardiac 
massage  is,  therefore,  not  essential. 

The  primary  purpose  being  to  determine  the  period  of 
anemia  which  the  central  nervous  system  can  endure  with 
subsequent  recovery,  the  method  offers  the  advantage  that  no 
operative  procedure  is  necessary  except  the  small  incision  for 
inserting    the   infusion   cannula.      The   author's    results   are 


lo  SURGICAL  ANEMIA  AND  RESUSCITATION 

based,  first,  on  a  series  of  thirty  unselected  dogs,  resuscitated 
after  the  lapse  of  various  periods  of  time,  in  all  but  five  of 
which  the  subsequent  course  of  events  was  not  disturbed. 
These  five  were  killed  after  different  times  for  the  purpose  of 
histologic  examination.  Secondly,  the  series  of  sixty  experi- 
ments on  dogs,  previously  reported  in  the  paper  on  resuscita- 
tion, was  drawn  upon  for  data  pertaining  to  this  work.  In 
the  latter  experiments  blood-pressure  and  respiratory  tracings 
were  made. 

Technique 

For  the  recovery  experiments,  with  one  exception,  the  dogs 
were  killed  with  chloroform.  While  open  to  objection  on 
account  of  the  paralyzing  effect  on  the  nervous  system,  and 
non-elimination  of  the  chloroform  until  after  the  resuscita- 
tion, this  method  was  adopted  in  imitation  of  the  condition 
most  likely  to  afford  opportunity  for  resuscitative  measures  in 
failure  of  the  heart  in  the  course  of  surgical  operations.  All 
procedures  were  done  with  the  customary  aseptic  precautions. 
The  infusion  cannula  was  inserted  into  the  axillary  artery. 

In  order  to  estimate  in  some  measure  the  effect  of  the 
anesthesia  on  the  subsequent  recovery  of  the  dogs,  two  experi- 
ments were  done  in  which  the  dog  was  anesthetized  in  the 
usual  way  to  the  point  of  respiratory  failure  and  was  then 
resuscitated  by  artificial  respiration  without  cessation  of  the 
circulation  being  permitted.  The  first  dog  showed  full  return 
to  intelligence  in  sixteen  minutes.  The  second  one  took  ether 
like  an  alcoholic  patient,  it  being  forced  for  ten  minutes  before 
struggling  ceased.  However,  in  twenty  minutes  after  recur- 
rence of  the  respiration,  the  animal  walked  about  and  showed 
return  of  function,  though  extremely  "groggy." 

The  period  of  total  anemia  was  estimated  to  start  from 
the  moment  when  the  first  heart  sound  ceased  to  be  audible 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM       II 

with  the  stethoscope,  this  sound  sometimes  persisting  for  sev- 
eral minutes  after  the  failure  of  blood-pressure  as  recorded 
upon  the  drum  and  the  disappearance  of  the  carotid  or  femoral 
pulse  and  the  second  sound.  While  this  is  only  the  statement 
of  a  well-known  fact,  attention  is  called  to  it,  because  very 
possibly  in  some  experiments  it  made  the  stated  period  of 
anemia  shorter  than  it  actually  was,  the  circulation  being  too 
feeble  to  reach  the  brain,  although  the  first  heart  sound  was 
still  audible.  In  some  cases  on  account  of  the  heart  sounds 
becoming  fainter,  it  was  impossible  to  record  the  actual  mo- 
ment of  failure.  In  these  a  leeway  of  at  least  one-half  minute 
was  allowed  from  the  last  distinct  sound  to  the  recorded  cessa- 
tion. From  the  time  of  starting  the  chloroform  to  respiratory 
failure  there  was  an  average  of  two  and  three-fourths  min- 
utes, with  a  minimum  of  fifty  seconds  and  a  maximum  of 
seven  and  five-twelfths  minutes.     (See  Table  I,  page  50.) 

The  cessation  of  respiration  and  the  final  failure  of  the 
heart  were  synchronous  in  five  cases;  from  which  the  inter- 
vening time  varied  up  to  six  and  three-fourths  minutes,  with 
an  average  of  one  minute  and  fifty-seven  seconds.  From  a 
study  of  the  tracings  of  the  first  series  it  was  found  that  the 
blood-pressure  was  at  the  base  line  during  a  longer  average 
time  than  the  latter  half  of  this  period.  It  is  probable,  there- 
fore, that  during  this  period  the  cerebral  circulation  was  re- 
duced nearly  to  the  vanishing  point,  and  while  a  small  amount 
of  blood  goes  a  long  way  in  the  brain,  Leonard  Hill  saying, 
"It  is  obvious  that  the  cortex  can  be  kept  from  death  for  hours 
by  the  merest  dribble  of  blood,"  this  marked  anemia  of  several 
minutes'  duration  had  an  effect  which  was  apparent  in  that 
the  cases  with  prolonged  partial  anemia  did  not  recover  as 
readily  as  did  the  average  dog  subjected  to  total  anemia  of 
equal  duration.  It  is  worthy  of  note  that  in  the  dog  showing 
the  maximum  recovery  period,  which  was  one  and  one-third 


12  SURGICAL  ANEMIA  AND  RESUSCITATION 

minutes  above  the  time  of  the  second  best  result,  only  twenty- 
two  seconds  intervened  between  respiratory  and  cardiac 
failure. 

In  five  out  of  the  twenty-nine  animals  killed  by  chloroform 
there  was  a  brief  spontaneous  recurrence  of  the  heart  sounds, 
occurring  from  twenty  seconds  to  one  and  one-half  minutes 
after  they  had  entirely  ceased,  and  accompanied  in  two  in- 
stances by  two  or  three  faint  respiratory  efforts.  In  only  one 
instance  was  the  carotid  pulse  palpable.  As  the  total  duration 
of  anemia  cannot  be  exactly  classified,  both  the  absolute  and 
practical  duration  will  be  given.  The  time  spent  in  resuscita- 
tion is  included  in  the  period  of  total  anemia. 

While  it  seems  reasonable  to  suppose  that  centripetal  arte- 
rial infusion  of  salt  solution  aided  by  indirect  massage  of  the 
heart  would  hardly  reach  the  brain  to  any  extent  during  a 
period  of  administration  of  from  one  to  three  minutes,  and, 
further,  as  if  it  did  there  would  be  very  little  blood  in  the  salt 
solution,  the  question  was  put  to  the  test  of  experiment.  In  a 
dog  which  had  been  dead  for  twelve  minutes  a  solution  of 
methylene  blue  was  infused  into  the  axillary  artery,  and  the 
usual  procedures,  with  the  exception  of  adrenalin  injection, 
were  carried  out  for  double  the  average  time.  No  indication 
of  its  having  reached  even  the  bulbar  centers  was  found.  This 
is  in  contradistinction  to  direct  massage,  which,  according  to 
d'Halluin,  effects  a  veritable  artificial  circulation,  which  is 
sufficient  to  reanimate  and  maintain  bulbar  activity.  Study 
of  the  tables  of  Prus  shows  that  as  a  result  of  direct  massage 
respiration  returned  in  twenty-nine  out  of  thirty-five  experi- 
ments in  one  series,  though  there  was  no  return  of  effective 
heart  beat,  and,  in  seven  cases,  reflexes  and  muscular  move- 
ments reappeared. 

The  definition  of  the  end  of  the  period  of  total  cessation  of 
the  circulation  was,  however,  sharp,  the  resumption  of  func- 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM       13 

tion  on  the  part  of  the  heart  being  abrupt  and  visible  as  well  as 
palpable.  After  a  few  initial  heart  sounds  blood-pressure  rose 
rapidly,  often  within  ten  seconds,  to  as  much  as  200  mm.  of 
mercury  or  over,  this  rise  being  due  to  the  adrenalin. 

Recovery  Results  (Tables  I  and  II,  pages  50  and  51.) 
Permanent  and  complete  recovery  was  obtained  after  five 
minutes,  six  minutes,^  six  minutes  and  ten  seconds,  six  min- 
utes and  fifteen  seconds,^  and  seven  minutes  and  thirty  sec-' 
onds  of  total  cessation  of  the  circulation.  That  is,  one  dog 
out  of  twelve  with  total  cessation  of  circulation  between  the 
periods  of  seven  minutes  and  eight  and  one-half  minutes  re- 
covered, whereas  only  one  out  of  seven  between  the  periods  of 
five  minutes  and  six  and  one-half  minutes  died  apparently  as 
a  direct  result  of  the  anemia.  Complete  recovery  was  pre- 
sumptive in  another  dog  after  cessation  of  circulation  for 
seven  minutes  and  thirty  seconds.  One  dog  of  the  second 
series,  after  cessation  for  five  minutes  and  thirty  seconds,  was 
killed  after  twenty-four  hours  for  the  purpose  of  histological 
examination.  As  compared  with  the  others  of  the  same  degree 
his  condition  assured  a  probable  recovery.  The  asphyxiated 
dog,  after  cessation  for  five  minutes  and  forty-five  seconds, 
was  killed  on  the  fourth  day.  A  second  animal  of  the  first 
series,  after  seven  minutes'  cessation,  was  killed  on  the  third 
day. 

Our  experience  showed  no  intermediate  condition  uncom- 
plicated by  accidental  organic  lesion ;  in  other  words,  no  slow 
decline  to  death.  The  demarcation  between  recovery  and 
death  was  sharp.  In  practically  all  the  experiments  the  crisis 
was  reached  in   from  twelve  to  twenty-four  hours.     Then 


^  Recurrence  of  heart  sounds  interjected  for  thirty  seconds ;  practical 
time,  six  minutes  and  thirty  seconds. 

^  Recurrence  of  heart  sounds  for  one  minute  and  twenty  seconds ; 
practical  time,  six  minutes  and  thirty-five  seconds. 


14  SURGICAL  ANEMIA  AND  RESUSCITATION 

death  ensued  quickly,  or  else  distinct  improvements  of  nervous 
functions  began  shortly,  continuing  more  or  less  rapidly  until 
complete  restoration,  though  the  convalescent  period  lasted  in 
two  dogs  four  and  six  weeks  respectively. 

From  his  studies  on  the  effect  of  different  degrees  of 
anemia  produced  by  occlusions,  Leonard  Hill  says :  "The 
degree  of  anemia  required  to  produce  dementia  is  separated 
by  the  narrowest  line  from  that  which  produces  coma  and 
death  of  the  respiratory  center.  There  are  either  no  symp- 
toms or  death  in  a  few  hours."  Our  results  accord  with  this 
statement.  Up  to  a  certain  point,  not  to  be  exactly  limited, 
but,  roughly,  six  minutes,  the  after-effects  are  not  marked, 
and  the  second,  third,  or  fourth  day  brings  complete  recovery. 
For  example,  one  dog  (Experirnent  lo),  after  four  minutes 
and  ten  seconds'  cessation  of  circulation  in  less  than  one  hour 
showed  entire  return  of  intelligence,  which  was  evinced  partly 
in  well-defined  efforts  to  escape  from  the  laboratory;  while 
another,  after  six  minutes  and  ten  seconds  (Experiment  29), 
showed  general  return  of  function  within  twenty-four  hours. 
Beyond  the  six-minute  limit,  however,  there  is  a  great  deal  of 
after-effect,  which  increases  disproportionately  with  the  in- 
crease in  the  duration  of  the  period  of  anemia,  in  some  in- 
stances reaching  a  state  in  which  the  animal  is  little  more  than 
a  cardio-respiratory  mechanism. 

Beyond  this  limit  recovery  is  altogether  uncertain,  but  our 
experiments  indicate  that  the  stage  of  depression  is  tided  over, 
and  that  recovery  will  be  complete  eventuall}^  though  the  nar- 
rowness of  the  escape  is  shown  by  the  degeneration  of  a  cer- 
tain number  of  neurons  in  the  recovered  dogs,  whose  brains 
were  studied  by  the  Marchi  method.  This  does  not  exclude 
the  possibility  of  a  partial  recovery  with  a  permanent  localized 
after-effect,  such  as  the  paralysis  of  one  foreleg,  a  result  de- 
scribed by  Stewart  in  two  animals  which,  however,  were  under 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  15 

observation  only  seven  and  nine  days,  respectively.  In  our 
dog,  which  recovered  after  anemia  of  the  maximum  duration, 
the  degeneration  predominated  in  the  pyramidal  fasciculus. 
The  distinction  here  has  reference  to  the  ability  of  the  whole 
organism  to  maintain  any  life.  The  viability  of  the  vital  cen- 
ters, as  well  as  of  other  centers,  is  considerably  above  that  of 
the  brain  as  a  whole,  as  the  recovery-results  prove,  and  the  im- 
mediate outcome  must  depend  on  the  maintenance  of  the  inter- 
relation and  association  of  all  brain  centers,  cortical  and  sub- 
cortical. Stewart  says  that,  when  exposed  to  adverse  influ- 
ences, the  synapse  proves  the  weak  link  in  the  nervous  chain. 

In  general  the  following  sequence  of  return  of  the  various 
functions  and  reflexes  was  exhibited :  respiration,  vasomotor 
control,  corneal  reflex,  and  knee-jerk  (tendon  reflexes  in  gen- 
eral), winking,  cutaneous  reflexes,  partial  or  complete  con- 
traction of  pupils,  and  light  reflex.  This  order  was  subject  to 
considerable  variation,  which  will  be  considered  under  the 
special  discussion  of  functions  and  reflexes.  Hypertonicity  of 
the  voluntary  musculature  immediately  succeeded  the  recovery 
of  a  normal  tone,  and  was  manifested  by  exaggeration  of  the 
knee-jerk,  if  not  by  a  more  or  less  widespread  spastic  condi- 
tion. This  hypertonicity  always  immediately  followed  the 
reappearance  of  the  knee-jerk. 

Reflex  muscular  movements,  the  result  of  skin  or  tendon 
stimulation,  always  preceded  those  of  spontaneous  origin. 
Spontaneous  incoordinate  movements  appeared  sometimes  be- 
fore, sometimes  after,  the  light  reflex,  but  their  later  appear- 
ance occurred  only  when  the  light  reflex  returned  relatively 
early.  Succeeding  the  coordinate  movements  appeared  what 
may  be  classed  as  purposeful  movements,  attempts  to  turn 
over,  to  arise,  or  to  crawl  forward — movements  involving  all 
the  muscles  of  locomotion.  Usually  after  the  appearance  of 
coordinate  movements,   auditory   and  visual   reactions   reap- 


1 6  SURGICAL  ANEMIA  AND  RESUSCITATION 

peared,  the  former  being  always  the  more  definite,  and  usually- 
returning  first.  In  many  of  the  dogs  that  succumbed  after 
some  hours  there  was  more  than  a  mere  revival  of  the  re- 
flexes;   some  of  the  higher  faculties  reviving  also. 

The  course  of  events  after  resuscitation  may  be  summar- 
ized as  follows :  A  state  of  hyperexcitability  follows  reani- 
mation,  reaching  its  maximum  in  from  one  to  three  hours, 
when  retrogression  begins.  This  second  stage  is  characterized 
by  uncontrolled  muscular  movements,  either  coordinate  or 
convulsive,  lasts  a  longer  time,  and  passes  gradually  into  the 
third  stage  of  depression  and  paralysis,  in  which  the  reflexes 
are  more  or  less  impaired.  The  dogs  which  recovered  never 
exhibited  as  much  mentality  nor  such  active  reflexes  on  the 
second  day  as  they  did  immediately  after  resuscitation. 

The  average  picture  toward  the  end  of  the  first  stage  in  a 
recovery  dog  is  of  an  animal  in  a  condition  of  stupor,  lying 
quietly  for  the  most  part,  with  an  accelerated  pulse  and  quick- 
ened respiration,  expiration  being  prolonged  and  labored; 
with  normal  conjunctival  reflexes;  with  cutaneous  reflexes 
constantly  present  in  the  limbs;  with  exaggerated  tendon  re- 
flexes; and  with  pupil  reflexes  uneven  and  tardy  if  expressed 
at  all.  There  is  a  general  spastic  condition  of  the  muscles,  the 
legs  being  commonly  held  in  extension.  After  loud  sounds 
in  close  proximity  the  head  may  be  raised,  the  eyelids  opened 
with  dilating  pupils,  and  the  ears  pricked  up,  the  attitude  being 
simply  one  of  attention  without  localization  or  any  indication 
of  ideation.  As  a  result  of  a  flash  of  light  the  head  may  be 
withdrawn,  but  usually  there  is  only  a  lid  reflex.  When  dis- 
turbed, and  sometimes  without  apparent  cause,  the  animal 
rouses,  barks,  looks  around,  and  exhibits  coordinate  and  even 
purposeful  and  propulsive  movements  of  the  legs  and  body, 
attempts  to  rise  or  to  crawl,  usually  unsuccessfully,  but  at 
times  succeeds  in  standing  or  in  making  short  progression  for 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  17 

a  few  seconds,  depending  on  the  extent  of  the  paralysis,  and 
then  again  falls  into  stupor. 

The  second  stage,  retrogression,  was  a  constant  phenom- 
enon in  all  the  dogs,  but  was  much  less  marked  after  the 
shorter  periods  of  anemia.  The  animal  becomes  progressively 
more  comatose;  the  spastic  condition,  which  had  largely  dis- 
appeared with  the  reanimation,  returns;  visual  and  auditory 
reaction  disappear;  and  the  skin  reflexes  become  inconstant. 
Muscular  movements,  however,  are  kept  up,  but  are  less  coor- 
dinate and  less  spasmodic,  their  character  apparently  depend- 
ing on  the  duration  of  the  anemia,  as  convulsive  movements 
are  slight  after  the  shorter  anemias,  while,  on  the  other  hand, 
the  dog  which  recovered  after  anemia  of  the  maximum  dura- 
tion had  definite  tono-clonic  convulsions.  When  such  convul- 
sive movements  are  well  marked,  the  animal  later  passes  into 
a  deep  coma,  with  a  general  condition  from  which  recovery 
hardly  seems  possible.  This  coma  lasts  from  6  to  12  hours, 
but  on  the  second  morning  a  distinct  improvement  is  apparent. 

Up  to  this  point  the  course  of  events  in  the  animals  which 
succumbed  was  similar  to  that  in  the  dogs  which  eventually 
recovered.  In  the  fatal  cases  a  few  did  not  attain  a  light 
reflex,  and  the  majority  recovered  as  far  as  to  exhibit  coor- 
dinate movements  and  auditory  reaction;  in  but  two,  how- 
ever, was  there  apparently  dim  consciousness.  Reanimation 
of  the  higher  faculties  was  much  more  transient,  if  present 
at  all,  and  the  animal  passed  quickly  into  coma,  from  which  it 
was  impossible  to  arouse  it.  There  were  sometimes  periods 
of  violent  convulsive  movements  alternating  with  periods  of 
quiet  and  stupor.  While  these  muscular  movements  were 
partly  clonic  and  tono-clonic  in  character,  they  were  distinctly 
propulsive  and  progressive,  though  violent  and  uncontrolled. 

Of  the  coordinate  movements,  the  running  motion  of  the 
legs,  such  as  is  frequently  seen  in  the  early  stages  of  anes- 


1 8  SURGICAL  ANEMIA  AND  RESUSCITATION 

thesia,  was  the  best  example,  and  was  performed  with  extreme 
rapidity,  the  dog  lying  partly  on  its  back  with  its  legs  waving 
rhythmically  in  the  air.  Sometimes  only  the  forelegs  were 
involved,  but  usually  the  movement  was  general.  If  the  dog 
was  not  too  much  paralyzed,  this  resulted  in  a  crab-like  pro- 
gression about  the  room.  The  strictly  convulsive  movements 
were  very  complex,  clonic  and  tonic  types  being  mingled,  with 
a  resultant  violent  thrashing  about.  In  several  instances  there 
was  some  opisthotonos.  The  slightest  disturbance  provoked 
movements  characteristic  of  the  animal. 

The  quiet  periods  in  the  early  stages  were  of  short  dura- 
tion, but  the  intervals  between  them  were  distinct.  In  the 
later  stages  the  intermediate  periods  of  rest  became  more  and 
more  prolonged.  Finally,  as  if  worn  out,  quiet  would  ensue, 
the  animal  being  perfectly  limp ;  tendon  and  skin  reflexes  dis- 
appearing first,  next  the  eye  reflexes,  until  only  the  cardio- 
respiratory functions  were  left  complete,  with  respiratory  fail- 
ure near. 

To  show  the  slow  return  of  faculties  and  the  paralyzing 
effect  of  the  maximum  period  of  anemia  from  which  recovery 
was  made  (seven  minutes  and  thirty  seconds  in  Experiment 
2.y),  the  subsequent  course  of  the  animal  in  this  experiment 
will  be  given  in  some  detail.  On  the  second  day  she  was  awake 
but  paid  no  attention  to  her  surroundings.  To  loud  sounds 
there  was  only  an  occasional  response,  and  blindness  appeared 
absolute.  The  hind  legs  were  entirely  paralyzed,  but  when 
the  hind  quarters  were  supported  she  was  able  to  walk  on  the 
forelegs,  though  the  progression  was  cross-legged  or  sprawl- 
ing. Sensation  was  much  more  deficient  than  motion,  no 
attention  being  made  to  the  prolonged  immersion  of  any  foot 
in  cold  water.  A  strong  bulldog  clamp  on  a  hind  paw  pro- 
voked restlessness  only,  though  on  a  forepaw  it  was  vaguely 
localized,  but  only  to  the  extent  of  a  reflex  from  the  leg  itself, 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  19 

there  being  no  coordinate  attempt  at  removal.  Food  was  not 
recognized  when  placed  in  the  mouth,  and  was  held  there  pas- 
sively. No  notice  was  taken  of  tobacco  smoke  or  ether  vapor. 
On  the  third  day  she  walked  about,  though  unsteadily,  and 
with  a  decided  stringhalt  gait  of  the  hindlegs.  She  recognized 
water  after  standing  in  it  for  several  minutes.  The  legs  gave 
way  when  she  jumped  off  a  chair.  Hearing  was  very  acute, 
but  vision  appeared  to  go  no  farther  than  the  mere  perception 
of  light.  That  localization  of  sensation  was  improved  was 
shown  by  the  clamp  test,  as  she  bit  rather  aimlessly  and  very 
incoordinately  at  the  foot  affected,  very  frecjuently  attacking 
the  wrong  leg.  It  was  not  until  the  seventh  day  that  the  clamp 
was  recognized,  grasped  and  pulled  off.  On  the  third  day  the 
feet  were  withdrawn  from  cold  water,  but  the  sense  of  posi- 
tion was  not  evident  until  the  fourth  day,  this  being  tested  by 
resting  the  feet  on  boards  at  different  levels.  Only  maximum 
differences  of  levels  were  recognized.  While  the  animal  ap- 
peared hungry,  constantly  licking  her  chops,  food  was  not 
recognized  until  the  fifth  day.  Tobacco  smoke  and  ether 
vapor  were  not  noticed  until  a  week  after  resuscitation.  While 
within  a  week  the  return  of  all  the  faculties  with  the  excep- 
tion of  vision  was  indicated  to  a  greater  or  less  degree,  the 
animal  was  by  no  means  normal,  but  exhibited  great  hebetude 
in  all  Vespects.  She  was  very  lethargic,  would  not  run  nor 
play,  and  response  to  any  stimulus  was  delayed  and  feeble. 
How  much  of  this  lethargy  was  due  to  the  blindness  it  was 
impossible  to  say,  but  certainly  not  all.  For  two  weeks  there 
was  hardly  any  perceptible  improvement  in  vision.  She  paid 
no  attention  to  the  attempts  to  test  her  vision,  and  she  moved 
about  slowly,  feeling  her  way,  though  at  about  the  end  of  the 
second  week  she  noticed  moving  objects  if  within  the  range  of 
a  foot  or  two,  especially  when  they  were  held  above  the  level 
of  her  eyes.    From  this  time  on  improvement  continued  stead- 


20  SURGICAL  ANEMIA  AND  RESUSCITATION 

ily,  and,  at  the  end  of  the  fourth  week,  recovery  of  vision  was 
complete.  With  the  recovery  of  vision  the  condition  of  de- 
mentia entirely  disappeared,  and  then  for  the  first  time  the 
psychical  faculties  of  fear,  pleasure,  and  memory  became  nor- 
mally evident. 

In  the  case  of  the  dogs  which  succumbed  the  following 
observations  were  made:  Among  seven  dogs  subjected  to 
anemia  lasting  from  five  to  seven  minutes,  one  died  after 
twenty-four  hours.  Of  those  which  died  after  anemia  from 
five  to  seven  minutes  in  extent,  two  revived  enough  to  exhibit 
spontaneous  coordinate  muscular  movements,  without  visual 
or  auditory  reactions  or  return  to  consciousness.  Of  five 
which  succumbed  after  eight-minute  to  nine-minute  periods  of 
anemia,  one  did  not  recover  sufficiently  to  show  even  the  light 
reflex,  and  did  not  come  out  of  coma;  two  recovered  to  the 
extent  of  muscular  motion;  a  fourth  recovered  auditory  re- 
action; while  in  only  one  was  there  a  suggestion  of  a  return 
to  consciousness.  Among  three  subjected  to  from  nine-  to 
ten-minute  periods  of  anemia  one  recovered  so  far  as  to  ex- 
hibit apparent  consciousness,  one  failed  to  recover  the  power 
of  vision,  and  in  the  third  the  light  reflex  returned.  One  dog 
after  anemia,  lasting  for  twelve  minutes  and  ten  seconds, 
showed  only  a  revival  of  the  reflexes,  and  in  the  dog  which 
recovered  after  the  longest  period  of  anemia  only  coordinate 
muscle  movements  appeared  in  addition  to  the  reflexes. 

Special  Phenomena  Following  Resuscitation 

Respiration. —  (See  Table  III,  page  52.)  Respiration  has 
recurred  in  every  animal  in  which  the  circulation  was  restored 
and  maintained  for  a  sufficient  period.  The  maximum  case, 
thirty-two  minutes  of  total  anemia,  twenty-one  minutes  after 
the  circulation  was  established,  showed  return  of  respiration 
to  the  extent  of  three  faint  gasps,  but  cardiac  failure  imme- 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  21 

diately  ensued.  Comparison  of  the  time  of  restoration  of 
respiration  in  our  experiments  shows  a  much  more  rapid  re- 
covery than  that  recorded  by  several  other  observers.  In  our 
experiments  the  average  time  for  the  restoration  of  animals 
subjected  to  anemia  for  periods  of  from  three  to  eight  minutes 
was  three  minutes  and  fourteen  seconds.  The  average  recov- 
ery time  in  Stewart's  cats  and  dogs  after  occlusion  of  vessels 
for  the  same  periods  was  seven  minutes  and  forty-one  sec- 
onds; for  Prus's  chloroform  series  with  periods  from  three  to 
five  and  one-half  minutes  was  seven  minutes  and  nineteen  sec- 
onds (with  frequent  return  of  respiration  before  efficient 
heart  beats).  Batelli's  successful  chloroform  cases  with  the 
same  periods  are  too  few  for  comparison,  but,  in  general,  both 
these  and  the  electrocuted  dogs  gave  data  in  concordance  with 
the  above  results.  Hill  says  that  a  certain  arterial  pressure  is 
necessary  to  invoke  respiration.  This  explains  the  increased 
effectiveness  of  the  higher  blood-pressure  due  to  the  adrenalin 
used  in  the  author's  experiments. 

The  first  respiratory  gasps  were  distinct  and  fairly  strong. 
In  the  majority  of  the  animals  after  a  few  gasps,  inspiration 
exhibited  a  triple  character,  with  the  inspiratory-expira- 
tory  ratio  of  three  to  one,  such  as  occurs  in  sobbing.  This 
lasted  for  several  minutes.  Gradually  the  rate  increased  and 
the  rhythm  became  regular.  A  sudden  resumption  of  the  nor- 
mal type  of  breathing  sometimes  happened  in  the  dogs  sub- 
jected to  short  duration  of  anemia,  and  was  always  associated 
with  the  simultaneous  recovery  of  the  eye  reflexes.  A  rapid 
increase  of  rate  was  the  rule  in  all  cases,  as  much  as  loo  per 
minute  being  recorded,  but  usually  the  high  rate  did  not  long 
continue.  For  example,  it  was  72  per  minute  sixteen  minutes 
after  resuscitation  in  the  dog  which  recovered  after  anemia  of 
seven  and  one-half  minutes  and  fell  to  36  in  about  twenty 
minutes.     Later  it  was  subject  to  frequent  changes,  and  in 


22  SURGICAL  ANEMIA  AND  RESUSCITATION 

some  cases  a  normal  rate  was  not  established  until  the  third 
day.  As  the  rate  slowed,  a  prolonged  and  labored  expiration 
was  characteristic.  The  changes  of  rate  in  the  initial  respira- 
tions will  be  best  illustrated  by  reference  to  the  protocols  of 
two  experiments. 

EXPERIMENT    27 

Hound  puppy,  about  eight  months  old.  Seven  and  one-half  min- 
utes total  cessation  of  the  circulation. 

11.45.30. — Return  of  pulse  was  first  noticed. 

11.47.30. — First  respiration.  The  first  four  respirations  occurred 
at  thirty-second  intervals,  and  then,  :':or  about  three  minutes  respira- 
tions occurred  at  seven-second  intervals,  each  inspiratory  act  com- 
prising three  distinct  efforts.  Fibrillary  contractions  of  the  tongue 
occurred  after  beginning  of  respiration. 

11.55.00. — Lacrimal  secretion  began.  The  right  pupil  was  dis- 
tinctly contracted. 

11.58.00. — Respirations  rather  suddenly  assumed  normal  char- 
acter and  rhythm,  with  rate  of  24. 

12.00.00. — Respiratory  rate  jumped  to  48. 

EXPERIMENT    30 

One-year-old  puppy.  Twelve  minutes  and  ten  seconds  total  ces- 
sation of  circulation. 

1 1.30. 15. — The  heart  began  to  beat,  recording  from  first  observa- 
tion of  the  pulse  in  the  axillary  cannula.  Though  the  infusion  tube 
was  partly  clamped  by  the  finger,  pressure  was  sufficient  to  drive  the 
blood  into  the  infusion  bottle  at  a  height  of  five  feet. 

11.32.25. — First  respiration  occurred.  This  movement  and  those 
following  for  several  minutes  were  deep  and  gasping.  For  four  min- 
utes the  rate  was  very  irregular,  at  intervals  varying  from  five  sec- 
onds to  one  minute.  Artificial  respiration  was  kept  up  continuously 
during  this  time,  but  was  stopped  as  soon  as  spontaneous  respirations 
became  more  regular. 

11.37.00. — Respirations  now  occurred  at  three  to  five-second  in- 
tervals. 

11.38.00. — Respiratory  rhythm  was  more  steady  (20  per  minute), 
and  movements  were  more  shallow. 

11.44.22. — Respirations,  28  per  minute. 

12.00.00. — Respirations,  32  per  minute,  were  somewhat  more  ir- 
regular and  spasmodic.     Expiration  was  distinctly  labored. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  23 

12.13.00. — Respirations,  40. 

12.40.00. — Respirations,  32.  The  dog  was  evidently  failing,  and 
about  one  hour  later  was  found  dead. 

Blood  Pressure. — (See  Table  III,  page  52.) — The  use  of 
adrenalin  complicated  the  study  of  the  blood-pressure  changes. 
In  a  successful  resuscitation,  as  already  noted,  the  blood  pres- 
sure rose  rapidly,  often  within  ten  seconds,  usually  to  a  height 
of  200  mm.  of  Hg,  and  in  one  case  to  250  mm.  This  level  was 
maintained  from  two  to  five  minutes  in  all  but  the  dog  with 
250  mm.  of  pressure,  and  then  it  began  to  fall  as  the  effect  of 
the  adrenalin  wore  off.  From  ten  to  forty  minutes  elapsed  be- 
fore the  lowest  level  was  reached.  Depending  on  the  extent  of 
the  vasomotor  reactivation,  either  a  tendency  to  rise  was  im- 
mediately exhibited  or  the  low  level  persisted  for  from  ten  to 
twenty  minutes,  in  the  latter  case  with  a  subsequent  rise.  In 
two  animals,  after  total  anemic  periods  of  seven  minutes  and 
thirty  seconds  and  eight  minutes  and  thirty  seconds,  one  of 
which  at  least  may  be  credited  with  presumptive  recovery,  this 
second  level  was  maintained  until  the  animals  were  killed — in 
twenty-four  hours  and  in  five  and  two-thirds  hours  respec- 
tively— but  in  the  others,  all  with  anemia  of  longer  duration, 
it  was  only  a  temporary  reanimation  and,  along  with  the  re- 
flexes, steadily  declined  until  death. 

On  account  of  the  adrenalin  effect  in  overlapping  the  re- 
turn of  normal  vasomotor  activity,  particularly  after  the 
shorter  periods  of  anemia,  the  relative  time  of  the  reactivation 
of  the  vasomotor  center  could  not  be  absolutely  determined. 
Stimulation  of  the  sciatic  nerve  did  not  cause  the  usual  rise  of 
pressure  until  the  secondary  rise  had  begun,  and  respirations 
were  well  established  (see  Table  IV,  page  53). 

With  one  exception  respiration  in  all  experiments  returned 
well  before  the  end  of  the  first  fall  in  blood  pressure.  In  one 
experiment  of  the  second  series  as  little  adrenalin  as  possible 


24  SURGICAL  ANEMIA  AND  RESUSCITATION 

was  used :  the  anemia  lasted  five  and  one-half  minutes  and 
respiration  began  in  two  minutes  after  restoration,  while  reac- 
tion to  sciatic  stimulation  was  not  obtained  for  four  minutes. 
Synchronously  with  the  pressure  reaction,  respiration  rather 
suddenly  assumed  a  more  normal  type.  It  appears,  therefore, 
that  the  return  of  activity  in  the  vasomotor  center  is  nearly 
synchronous  with  the  return  of  respiration  after  the  shorter 
periods  of  anemia,  but  is  more  delayed  after  the  longer 
periods.  In  the  puppy  subjected  to  thirty-five  minutes  of 
anemia  there  was  apparently  no  vasomotor  reactivation. 

Reflexes. —  (See  Table  IV,  page  53.)  While  varying 
considerably  in  the  time  of  their  recurrence,  after  equal 
periods  of  anemia,  the  corneal  reflex  and  spontaneous  winking 
returned  in  all  but  the  three  experiments  which  were  not  suffi- 
ciently protracted.  The  light  reflex  reappeared  constantly 
after  eight  minutes  of  anemia,  though  it  was  the  least  uniform 
in  time  of  its  return  and  in  its  degree  of  activity.  In  periods 
of  anemia  of  more  than  eight  minutes  the  recovery  of  the 
light  reflex  was  inconstant.  The  maximum  anemia  period 
after  which  the  corneal  reflex  reappeared  was  twenty-four 
minutes  (maximum  resuscitation  in  adult  dogs),  and  for  the 
light  reflex  the  maximum  time  was  fourteen  and  one-half 
minutes. 

The  knee-jerk  varied  the  least  in  its  recovery  periods.  It 
was  also  noted  in  the  resuscitation  after  the  maximum  anemia 
period.  Not  infrequently  there  was  a  difference  in  the  time 
of  recurrence  of  the  bilateral  reflexes,  in  two  cases  one  corneal 
reflex  reappearing  three  minutes  before  the  other,  though  for 
the  knee-jerks  no  difference  of  over  one-half  minute  was 
noted. 

As  to  the  relative  time  of  the  reappearance  of  reflexes,  the 
knee-jerk  usually  appeared  before  the  corneal  reflex,  though 
they  were  synchronous  four  times.    The  corneal  reflex  always 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  25 

preceded  spontaneous  winking,  while  in  every  case  the  cutane- 
ous reflexes  returned  before  the  light  reflex. 

Temperature. — While  not  recorded  as  a  matter  of  routine, 
sufficient  data  have  been  obtained  to  indicate  that  the  tempera- 
ture continues  to  fall  for  several  hours  following  resuscita- 
tion. The  lowest  rectal  temperature  was  32.9°  C,  four  hours 
after  anemia  of  nine  and  one- fourth  minutes  (Experi- 
ment i),  and  33.8°  C.  was  reached  in  sixteen  minutes  after 
thirteen  and  one-third  minutes  of  anemia  (Experiment  5). 
From  this  point  the  temperature  gradually  rose  to  a  state  of 
hyperpyrexia,  which  was  more  marked  in  the  animals  which 
succumbed.  In  the  dog  which  recovered  after  the  maximum 
period  of  anemia  the  maintained  level  was  reached  the  second 
day. 

Phonation. — Nine  and  one-quarter  minutes  of  anemia 
(Experiment  i)  was  the  maximum  period  after  which  this 
faculty  returned.  Actual  barking,  indeed,  occurred  in  but  one 
other  case  of  over  seven  and  one-half  minutes  of  anemia  (Ex- 
periment 14),  though  there  was  whining  or  imperfect  attempts 
at  vocalization  in  three  cases.  Phonation  usually  appeared 
synchronously  with  or  shortly  after  the  exhibition  of  spon- 
taneous muscular  movements,  that  is,  one-half  to  one  hour 
after  resuscitations  following  anemia  of  about  seven  minutes. 

Micturition  and  Defecation. — Micturition  or  defecation  oc- 
curred in  the  majority  of  animals  during  the  period  of  hyper- 
excitability. 

Auditory,  Visual,  and  Olfactory  Senses. — As  already  indi- 
cated, the  reaction  to  auditory  stimuli  was  definite  and  unmis- 
takable during  the  period  of  hyperexcitability  in  the  recov- 
ered dogs,  while  to  various  visual  stimuli  during  the  same 
period  the  only  response  was  a  lid  or  pupil  reflex,  but  out  of 
fifteen  animals  subjected  to  anemia  for  seven  minutes  or 
more,  only  six  gave  even  a  temporary  recovery  of  hearing. 


26  SURGICAL  ANEMIA  AND  RESUSCITATION 

Further,  in  the  animals  which  recovered  the  later  effects  on 
vision  were  much  more  marked,  in  general  increasing  as  the 
limit  of  possible  recovery  was  approached.  For  example,  in 
the  dog  with  recovery  after  the  maximum  anemia  period, 
hearing  was  reasonably  acute  on  the  third  day,  though  vision 
was  not  fully  restored  for  three  weeks,  while  in  the  animal 
with  anemia  of  six  and  one-sixth  minutes  (Experiment  29), 
the  best  example  of  early  visual  recovery,  hearing  was  normal 
on  the  second  day,  though  a  day  more  was  required  before  the 
animal  ran  about  without  colliding  with  obstacles.  The  maxi- 
mum duration  of  anemia  after  which  hearing  was  observed 
was  nine  and  three-fourths  minutes  (Experiment  15).  The 
sense  of  smell  came  back  at  a  point  between  hearing  and 
vision,  though  the  test  was  never  definite  unless  irritating 
fumes  were  employed.  The  first  reaction  to  these  was  on  the 
third  and  seventh  days,  respectively,  in  dogs  with  anemia  of 
six  and  of  seven  and  one-half  minutes  (Experiments  2  and 

27). 

Phenomena  Referable  to  the  Cortex. — IMost  of  the  animals 

which  recovered  passed  through  a  final  stage  comparable  in 
many  respects  to  the  condition  of  Goltz's  decerebrates.  Such 
a  period  was  characterized  by  dementia  and  loss  of  intelli- 
gence, the  lack  of  any  psychic  response  to  stimuli,  and  the  in-: 
ability  to  recognize  food  and  drink.  Response  to  stimulation 
was  purely  reflex,  or  was  absent  if  memory  of  past  experiences 
was  involved.  For  example,  meat  placed  in  the  mouth  was 
held  there  passively  or  in  one  case  forcibly  spat  out,  a  flash  of 
light  was  answered  by  a  lid  reflex,  and  there  was  indifference 
to  the  relative  position  of  the  fore  legs.  Power  to  localize 
stimuli  was  of  gradual  acquirement.  Restlessness,  however, 
was  generally  not  observed. 

That  the  temporary  paralysis  was  of  cortical  origin  was 
indicated  by  the  associated  exaggeration  of  the  knee-jerks. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  27 

The  motor  function  did  not  suffer  as  much  as  the  sensory,  for 
the  paralysis  disappeared  before  the  return  of  intelhgent  and 
normal  response  to  stimulation.  The  clinical  observation  that 
the  cortex  suffered  the  most  and  was  the  last  to  recover  is 
supported  by  the  fact  that  the  histological  alterations  were 
more  marked  in  the  cortex  than  in  the  lower  centers. 

The  other  dog  which  recovered  also  gave  a  picture  of  de- 
generation, but  of  a  different  character.  While  the  actual 
number  of  nerve  fibers  involved  was  greater,  not  only  was 
there  no  localization  but  there  was  an  early  stage  of  degenera- 
tion with  droplets  of  varying  size,  scattered  in  longitudinally 
cut  spinal  nerves  at  intervals  along  the  course  of  the  fibers 
affected.  This  animal,  which  was  killed  in  six  days,  was,  at 
the  time  of  death,  partially  blind  and  deaf  and,  though  it  could 
stand,  it  was  too  paralyzed  to  maintain  the  upright  posture  or 
to  walk.  The  question  arises  as  to  whether  it  would  have 
eventually  recovered.  Judging  from  the  other  animals  which, 
with  final  recovery,  passed  somewhat  more  rapidly  through  a 
sirpilar  condition,  and  from  the  fact  that  there  was  a  notice- 
able improvement  from  day  to  day  in  the  animal  just  men- 
tioned, general  recovery,  with  a  complete  destruction  of  a  few 
neurons,  is  probable. 

An  early  degeneration  similar  to  that  mentioned  occurred 
in  the  fatal  cases,  though  the  number  of  fibers  involved  was 
considerably  less.  None  of  these  animals  had  lived  over 
thirty-six  hours  at  the  outside.  On  account  of  the  shortness 
of  the  time  which  had  elapsed,  this  appearance  was  unexpected 
and  will  be  further  investigated.  However,  it  corresponds 
with  the  organic  changes  in  the  cell-bodies  which  occurred 
during  the  same  time. 


28  SURGICAL  ANEMIA  AND  RESUSCITATION 

Comparison  of  the  Authors'  Results  with  the  Results  of 

Others 

Mayer  concludes  that  from  ten  to  fifteen  minutes  of 
anemia  is  the  maximum  period  admitting  of  general  resusci- 
tation, though  respiration  and  the  vasoconstrictor  activity  may 
recover  after  that  time.  Stewart,  with  complete  recoveries 
after  occlusion  of  cerebral  vessels  for  five,  six,  eight,  nine  and 
four-fifths,  and  sixteen  and  one-half  minutes,  agrees  with 
Mayer's  conclusion.  Hayem  says  that,  in  general,  brain  func- 
tions are  not  recovered  after  from  ten  to  eleven  minutes. 
The  conclusions  of  Batelli  and  of  Prus  are  the  only  ones 
drawn  from  observation  of  animals  resuscitated  from  ap- 
parent death.  None  of  Batelli's  dogs  survived,  and  he  ascribes 
this  fact  to  the  severity  of  the  operation  on  the  thorax  neces- 
sary for  his  resuscitative  measures  of  electrical  stimulation 
and  heart  massage.  He  states  that  its  condition  being  aggra- 
vated by  the  violent  respiratory  efforts,  the  animal  passes  into 
coma  and  dies.  However,  from  the  extent  of  reanimatjon 
exhibited,  he  concludes  that  the  functions  of  the  central  nerv- 
ous system  may  be  reestablished  after  ten  minutes  of  total 
anemia,  but  not  constantly  after  fifteen,  and  that  the  maximum 
limit  is  twenty  minutes.  Prus  does  not  fix  a  definite  limit. 
Stewart  suggests  that,  in  such  prolonged  periods  of  one  and 
two  hours  as  those  of  Prus,  the  auricles  must  have  kept  up  a 
slow,  but  in  some  degree  efficient,  movement  of  the  blood 
through  the  brain.  On  account  of  the  injury  from  opening 
the  thorax,  Prus  attempted  recovery  in  only  thirteen  out  of 
fifty-two  reanimated  dogs,  the  others  being  killed  after  a 
short  time.  Two  of  these  survived.  One  was  killed  by  as- 
phyxiation, after  a  period  of  total  anemia  of  six  minutes, 
estimating  from  the  stoppage  of  the  heart  to  the  beginning  of 
direct  massage,  as  considered  under  "Technique."     From  the 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM       29 

data  given,  the  subsequent  course  of  this  animal  corresponds 
closely  to  the  author's  six-minute  anemia  cases.  The  other  of 
Prus's  recovery  dogs  after  an  anemia  period  of  four  minutes 
v^as  killed  by  chloroform.  The  dogs  that  survived  from  three 
to  five  days  were  all  subjected  to  anemia  of  short  dura- 
tion, and  of  the  two  cases  subjected  to  ten  minutes 
of  total  anemia,  one  died  in  six  and  one-half  and 
the  other  in  twenty-four  hours,  all  the  deaths  being  ascribed 
to  infection. 

From  the  author's  experience,  it  seems  justifiable  to  say 
that  the  observation  of  an  animal  resuscitated  from  a  state  of 
completely  suspended  animation  is  very  misleading  unless  car- 
ried far  enough,  and  that  such  observation  does  not  permit  of 
conclusions  regarding  the  limit  of  anemia  admitting  of  recov- 
ery. The  reason  is  that  there  quickly  ensues  a  condition  of 
hyperexcitability  of  reflexes  associated  with  voluntary  move- 
ments and  with  greater  or  less  return  of  the  special  senses, 
even  with  an  apparent  return  to  consciousness;  consciousness 
may  be  transient,  but  appears  in  animals  which  succumb  as 
well  as  in  those  which  eventually  recover.  This  phenomenon 
was  exhibited  in  dogs  subjected  to  nearly  twice  the  duration  of 
anemia  from  which  recovery  was  made,  and  in  several  in- 
stances the  appearance  of  reanimation  was  so  decided  as  to 
make  the  prognosis  very  hopeful.  But  after  a  few  hours,  more 
or  less,  the  special  senses  failed,  the  dog  became  progressively 
stuporous,  convulsions  ensued,  then  loss  of  reflexes,  and, 
finally,  respiratory  failure.  The  decline  to  death  indicated 
definitely  a  nervous  origin ;  and  autopsies  on  all  the  cases  fatal 
immediately  after  the  resuscitation  showed  in  only  one  case 
any  organic  lesion  to  which  death  could  be  attributed.  This 
was  a  dog  which  had  been  subjected  to  anemia  of  eight  and 
one-half  minutes  (Experiment  14)  and  which  died  between 
thirty  and  forty  hours  later,  with  an  early  and  irregularly  dis- 


30  suRGic.\L  axe:mia  axd  resuscitation 

seminated  bronchopneumonia.  As  long  a  survival  as  this  was 
exceptional. 

By  the  occlusion  method,  the  general  conclusion  appears 
to  be  that  ten  to  fifteen  minutes  of  anemia  is  the  maximum 
period  after  which  resuscitation  is  practicable.  This  conclu- 
sion is  not  unassailable  for  two  reasons;  first,  because  of  the 
impossibility  of  absolutely  eliminating  the  factor  of  collateral 
circulation,  and,  second,  because  the  brain  and  cord  have  been 
investigated  separately.  In  the  latter  connection,  apart  from 
the  interrelationship  of  the  two,  the  possible  percolation  up- 
ward of  the  cerebrospinal  fluid,  with  the  circulation  of  the 
cord  unimpeded,  is  worthy  of  consideration. 

As  a  result  of  the  authors'  experiments  with  an  undoubt- 
edly total  anemia  and  little  opportunity  for  infectious  acci- 
dents— conditions  the  most  favorable  for  investigation  of  the 
possibility  of  recovery — the  opinion  is  that  the  limit  should  be 
reduced  one-half.  For  dogs  killed  by  chloroform  the  average 
duration  of  anemia  from  which  recovery  may  be  made  is  be- 
tween six  and  seven  minutes.  The  extreme  limit  appears  to 
the  author  to  be  under  ten  minutes,  and  any  recovery  after 
more  than  seven  and  one-half  minutes  would  be  exceptional. 
The  accurate  fixation  of  the  limit  beyond  which  recovery  is 
impossible  is  of  great  practical  importance. 

Summary 

To  determine  the  limits  of  recovery  after  a  total  anemia 
of  the  central  nervous  system,  thirty  dogs  were  killed  by 
chloroform  and  resuscitated  after  the  lapse  of  varying  times 
of  from  three  to  fourteen  minutes.  If  resuscitated  in  less 
than  five  minutes  the  recovery  of  function  was  rapid  and  was 
strikingly  free  from  the  after-effects  which  characterized 
longer  periods.  Of  seven  animals  anemic  from  five  to  six  and 
one-half  minutes,  only  one  died  apparently  as  a  direct  result  of 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  31 

the  anemia,  but  of  twelve  subjected  to  anemia  from  seven  min- 
utes to  eight  and  one-half  minutes,  only  one  recovered  after 
seven  and  one-half  minutes  of  anemia.  The  remaining  dogs 
all  died.  Further  corroborative  data  are  drawn  from  the  pre- 
viously published  paper  on  the  technicjue  of  resuscitation. 

Histological  examination  both  of  presumptive  recoveries 
and  of  fatal  cases  was  made  by  ordinary  methods  and  by  those 
of  Nissl  and  Marchi.  The  neurocytes  of  the  fatal  cases  uni- 
formly presented  the  greatest  change,  being  not  merely  chrom- 
olytic  but  here  and  there  definitely  indicative  of  cell  death. 
Marchi's  method  further  supports  these  findings  by  proving 
the  existence  of  fiber  degeneration.  Finally,  showing  the  nar- 
rowness of  the  escape,  in  the  animal  showing  the  best  recov- 
ery-result after  seven  and  one-half  minutes  of  anemia,  which 
at  the  end  of  four  weeks  had  apparently  entirely  returned  to  a 
normal  state,  histological  examination  by  the  Marchi  method 
showed  the  degeneration  of  a  number  of  fibers  in  the  pyram- 
idal fasciculi,  which  were  traced  from  the  cord  to  the  cortex, 
and  in  Flechsig's  fasciculus,  while  a  more  sparsely  scat- 
tered degeneration  of  both  ascending  and  descending  fibers 
was  evident  elsewhere.  In  recent  works  (1911)  all  changes 
due  to  cerebral  anemia  have  been  much  more  extensively 
studied. 

Protocols  of  Ten  Selected  Experiments  -^ 

EXPERIMENT    i 

Death   from    Chloroform;    Resuscitation    Begun    5    Minutes   After 
Cessation  of  Circulation ;  Total  Duration  of 
Anemia,  9j4  Minutes 
July,  1906. 

Small  mongrel  dog;  fairly  nourished,  but  with  a  general  vesicular 
and  pustular  eruption.  A  cannula  was  inserted  into  the  axillary 
artery,  and  connected  by  means  of  rubber  tubing  with  the  saline  in- 

^  The  numbers  of  these  experiments  do  not ,  correspond  with  those 
given  in  the  foregoing  pages,  the  former  referring  to  the  tables. 


32  SURGICAL  ANEMIA  AND  RESUSCITATION 

fusion  bottle,  at  a  height  of  five  feet  above  the  operating  table.    Ether 

was  given  at  first,  and  then  chloroform  in  lethal  dose.    After  cardiac 

failure  a  tracheal  intubation  tube  v^^as  inserted,  so  that  artificial  respi- 
ration could  be  given  with  bellows. 

10.20.30  A.  M. — Respiration  ceased. 

10.21.30. — Respiration  began  again.     More  chloroform  was  given. 

10.22.     — Respiration  ceased. 

10.27.15. — Heart  sounds  ceased,  and  pulse  was  no  longer  palpable  (5 
minutes  and  15  seconds  after  final  cessation  of  respira- 
tion). 

10.32.15. — Began  to  resuscitate;  5  minutes  after  cessation  of  circula- 
tion normal  saline  solution  was  given  through  the  axil- 
lary cannula,  2  c.  c.  of  1-1,000  solution  adrenalin  chlorid 
solution  were  injected  through  the  rubber  tubing,  just 
above  the  cannula,  into  the  saline  stream,  by  means  of  a 
hypodermic  syringe,  and  artificial  respiration  was  begun 
with  the  bellows. 

10.36.30. — The  heart  began  to  beat,  making  the  total  duration  of  ces- 
sation of  circulation  9  minutes  and  15  seconds. 

10.40.  — Spontaneous  respiration  began,  4  minutes  15  seconds  after 
return  of  circulation. 

10.50.  — The  heart  sounds  were  distinct,  but  slow  and  somewhat  ir- 
regular, improving  from  this  time  on.  The  respiration 
was  regular  and  normal. 

10.55.  — The  respiration  suddenly  became  irregular.  Artificial  res- 
piration was  begun,  with  rapid  improvement  of  the  res- 
piration following. 

11.37.  — Conjunctival  reflexes  were  first  obtained,  i  hour  ij^  min- 
utes after  return  of  the  circulation.  The  heart  was 
apparently  acting  in  an  entirely  normal  manner.  The 
blood-pressure,  which  had  been  very  low,  was  about 
"  100  mm.   of  mercury,   in  so   far  as  it  could  be  judged 

from  the  pulse. 

11.43,  — Knee-jerks  were  obtained  in  the  left  hind  leg,  i  hour  7^^ 
minutes  after  return  of  the  circulation.  They  were 
then  obtained  in  the  right  hind  leg,  but  more  feebly. 

11.45.  — Respiration  was  normal.  The  intubation  tube  was  re- 
moved. There  was  some  slight  resistance  to  flexion  and 
extension  of  the  hind  legs,  but  the  fore  legs  were  com- 
pletely relaxed. 

11.47.  — The  knee-jerks  were  slightly  stronger.  The  pupils  were 
widely  dilated  and  with  no  reaction  to  light. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  33 

12.15.  — The  pupils  were  becoming  narrow,  and  were  just  begin- 
ning to  react  to  light,  i  hour  38^/^  minutes  after  return 
of  circulation.  The  general  muscular  tone  was  better, 
but  the  fore  legs  were  still  relaxed,  except  at  the 
shoulders.  Moving  the  neck,  especially  flexing  it,  was 
resisted.  The  spinal  muscles  resisted  when  the  back 
was  bent. 

12.50.  — The  hind  legs  were  somewhat  spastic,  flexed  at  the  thigh 
and  extended  at  the  knee.  The  fore  legs  were  still  more 
so.  The  muscles  of  the  back  were  not  spastic  on  flexion, 
but  were  somewhat  so  on  extension.  The  reaction  of 
the  pupils  to  light  was  active.  The  right  pupil  was 
much  more  active  than  the  left.  The  respiration  and 
blood-pressure  were  normal.  Spontaneous  defecation 
occurred,  4  hours  y/2  minutes  after  return  of  the  circu- 
lation. The  temperature  by  rectum  wis  32.9°  C.  The 
skin  was  very  cold. 

1.50.  — Temperature  33.3°  C.  The  condition  of  the  muscles  was 
the  same.  On  being  moved  the  dog  seemed  to  utter 
purposeful  moans,  and  showed  some  apparently  purpose- 
ful movements  of  the  fore  legs,  as  if  trying  to  get  up. 
The  pupils  were  of  normal  size,  the  left  being  slightly 
more  dilated  than  the  right.  When  not  disturbed  im- 
mediate general  relaxation,  followed  by  sleep,  took  place. 

2,00,  — At  about  this  time  and  shortly  after,  several  spontaneous 
periods  of  awakening  from  the  stupor  occurred,  the 
eyes  being  widely  opened,  while  purposeful  but  futile 
attempts  were  made  to  turn  over  and  stand  up.  After 
several  of  these  attempts  had  been  made  at  irregular  in- 
tervals one  was  induced  by  pounding  on  an  adjacent 
table.  The  dog  evidently  heard  the  noise,  as  he  opened 
his  eyes  and  tried  to  rise.  When  quiet  ensued  he  re- 
lapsed again  into  stupor.  When  the  hand  was  passed 
rapidly  in  front  of  his  eyes  he  blinked. 

4.00.  — The  dog  was  sleeping,  with  grunting  respirations.  On  be- 
ing disturbed,  he  rose  to  his  feet,  but  relaxed  at  once 
into  a  stupor,  and  fell  down.  Also  when  left  alone  he 
relaxed  into  stupor.  Apparently  he  was  able  to  see,  for, 
when  aroused,  he  looked  fixedly  but  vacantly.  A  mov- 
ing object  did  not  cause  winking  until  the  eyelids  were 
touched. 

5,30.       — The  spastic  condition  had  passed  off.    The  knee-jerks  were 


34  SURGIC-\L  ANEMIA  AXD  RESUSCITATION 

active,  but  there  -was  no  clonus.  A  comatose  condition 
was  present.  Loud  noises  did  not  disturb.  Under  stimu- 
lation spontaneous  attempts  at  forward  locomotion  oc- 
curred, the  movements  of  the  fore  legs  being  coordi- 
nated.    Relapse  immediately  followed  the  efforts. 

9.00.  — Temperature  not  taken,  but  dog  in  high  fever.  He  lay 
stretched  out  in  a  spastic  condition,  with  labored,  ster- 
torous, rapid  breathing,  which  soon  became  rapidly  irregu- 
lar and  gasping,  although  the  pulse  was  still  good.  The 
knee-jerks  had  almost  disappeared.  Death  was  evi- 
dently near  at  hand. 

9.15.  — Respiration  ceased.  The  heart  continued  to  beat  rhythmi- 
cally for  about  three  minutes  more.  Autopsy  was  per- 
formed before  the  heart  action  had  entirely  ceased. 
Autopsy :  The  heart  was  empty  and  apparently  normal. 
Xo  clots  were  present.  The  lungs  showed  nothing  of 
importance  except  slight  congestion  at  the  base.  In  two 
places  the  liver  had  been  slightly  injured  by  the  mas- 
sage. Both  liver  and  spleen  showed  a  chronic  inflam- 
matory change  of  no  interest  in  the  present  connection. 
The  other  organs  appeared,  to  be  normal. 

EXPERIMENT    2 

Death    from    Chloroform;    Resuscitation    Begun    3    Minutes    After 

Cessation   of  Circulation;  Total  Duration   of 

Anemia,  6^  Minutes 

July  25,  1906. 

Black  mongrel  bitch ;  weight,  about  7.0  kilos.     Experiment  con- 
ducted as  in  Experiment  i,  using  ether  at  first  and  then  the  lethal 

dose  of  chloroform. 

11.52.30.  A.  M. — Respiration  ceased. 

11.53.30. — Heart  action  no  longer  perceptible. 

11.54.30. — Heart  beats  appeared  again,  but  the  pulse  was  barely  per- 
ceptible. 

11.55.  — Heart  beats  ceased.  Pulse  no  longer  palpable.  The  cir- 
culation practically  ceased  at  11.52.30. 

11.58,  — Began  to  resuscitate  in  the  usual  way,  3  minutes  after 
final  cessation  of  circulation. 

12.00.  — Heart  beats   appeared,    making   the   duration   of   complete 

cessation  of  circulation  6^^  minutes. 

12.01.  — Spontaneous  respiration  began  45  seconds  after  return  of 

the  circulation. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  35 

12.09.  — Knee-jerk  appeared  in  the  left  hind  leg,  8  minutes  45  sec- 
onds after  return  of  the  circulation,  and  Yz  minute  later 
in  the  right  hind  leg,  9  minutes  15  seconds  after  return 
of  the  circulation. 

■12. II.  — Conjunctival  reflex  appeared  on  stimulation,  10  minutes  45 
seconds  after  return  of  the  circulation. 

12.13.  — The  fore  legs  began  to  stiffen,  and  incoordinate  muscular 
movements  occurred.  In  connection  with  the  latter  and 
in  conjunction  with  the  respiratory  efforts  movements 
of  the  head  first  appeared.  The  muscles  of  the  hind 
legs  became  tonic,  but  were  not  stiff. 

12.15.      — Spontaneous  winking  occurred. 

12.18.  — General  slight  spasmodic  muscular  contractions  occurred, 
while  the  muscular  movements  became  more  coordi- 
nated and  purposeful.     The  pupils  were  still  dilated. 

12.20.  — The  respirations  were  still  labored.  The  pulse  was  of 
good  quality.  The  pupils  began  to  narrow,  and  the  gen- 
eral  muscular   movements   continued. 

12.25.  — I'^  response  to  touching  the  skin  the  leg  was  drawn  away, 
showing  that  the  cutaneous  reflex  had  returned,  25  min- 
utes after  return  of  the  circulation. 

12.27.  — O^  lifting  the  dog  from  the  table  to  her  box  she  raised 
her  head  and  looked  toward  the  bearer.  The  breathing 
had  just  become  fairly  quiet  and  normal. 

12.32.      — A  spontaneous  attempt  to  get  up  was  made. 

12.35.     — The  dog  barked.    The  head  was  held  in  marked  extension. 

12.40.  — It  was  shown  by  slight  movements  of  the  eyes  or  head 
that  attention  was  paid  to  loud  sounds  made  by  ham- 
mering on  a  box.  To  loud  whistling  there  was  but 
slight  response.  The  pupils  were  still  dilated  greatly, 
but  showed  faint  reaction  to  light,  40  minutes  after  re- 
turn of  the  circulation. 

12.45.  — Notice  seemed  to  be  taken  of  the  surroundings.  The  ani- 
mal's general  appearance  might  be  described  as  being 
stupid.  Water  was  not  drunk,  even  when  the  nose 
was  placed  in  it. 

5.00.  — The  dog  was  apparently  brighter,  languidly  following 
movements  in  her  immediate  vicinity,  but  spent  the  time 
in  quietly  sleeping,  if  not  disturbed.  The  spastic  condi- 
tion had  almost  disappeared. 

9.30.  — She  was  found  ten  feet  away  from  her  box,  egress  having 
been  barred  by  a  side  six  inches  high,  over  which  she 


36  SURGICAL  ANEMIA  AND  RESUSCITATION 

had  climbed.  She  was  unconscious,  barely  arousing 
when  returned  to  the  box,  when  she  immediately  re- 
lapsed into  deep  stupor.  Loud  sounds  only  called  forth 
subdued  groans.  Defecation  occurred.  Temperature, 
40.1°  C.  Respirations  were  quiet  and  easy.  The  pulse 
was  of  high  tension  and  somewhat  thready.  Constant 
shivering  was  present.  The  knee-jerks  were  again  ex- 
aggerated, but  most  of  the  spasticity  of  the  legs  was 
lost.  On  being  pinched  the  general  spastic  condition 
returned.  Various  muscular  movements  occurred,  and 
occasionally  they  seemed  to  be  in  response  to  loud 
sounds. 

July  26,  1906. 

9.00  A.  M. — The  dog  was  found  quietly  sleeping.  The  pulse  was 
normal  in  character,  the  respiration  easy,  the  tempera- 
ture 39.5°  by  rectum.  The  knee-jerks  were  still  exag- 
gerated, but  the  legs  had  lost  most  of  their  spasticity. 
For  the  first  time  an  exaggerated  scratch  reflex  was 
obtained.  When  annoyed  by  flies  she  tried  to  wipe  them 
away  with  her  paws,  and  threw  her  head  toward  the 
point  of  irritation,  but  without  trying  to  bite  at  them. 
On  loud  whistling  the  eyes  were  barely  opened.  On 
suddenly  striking  a  match  in  front  of  her  eyes  only  a 
delayed  conjunctival  reflex  was  caused.  Attempts  to 
disturb  her  merely  roused  her  slightly  from  her 
stupor.  Petting  apparently  did  not  arouse  any  cere- 
bral ideation.  The  general  appearance  was  that  of  mod- 
erate morphin  anesthesia.  The  same  condition  was 
maintained  all  day,  the  dog  sleeping  quietly  when  undis- 
turbed. Twice  milk  was  given  her  by  means  of  a 
.  stomach  tube — 300  c.  c.  at  noon  and  500  c.  c.  at  night. 

July  27,  1906. 

9.00  A.  M. — The  dog  was  lying  outside  her  box.  When  put  on  her 
feet,  she  walked  aimlessly,  being  rather  shaky  and 
ataxic,  and  did  not  see  obstacles  in  her  path  in  time  to 
avoid  them.  Striking  a  match  suddenly  before  her  face 
caused  opening  and  blinking  of  her  eyes,  but  she  was 
perfectly  indifferent  to  a  light  moved  slowly  in  front  of 
her  eyes.  Only  once  did  loud  sounds  cause  her  to  move 
away  into  a  corner.  After  that  time  she  paid  no  atten- 
tion to  whistling,  or  to  stamping,  even  immediately  in 
front  of  her  head,  regarding  such  actions  with  a  vacant 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM       37 

stare.  The  odor  of  an  old  pipe  had  no  effect.  Chloro- 
form and  tobacco  smoke  caused  her  to  draw  her  head 
away,  but  this  was  considered  to  be  a  reflex  action. 
Patting  and  petting  brought  forth  only  a  scratch  reflex. 
Water  was  refused,  even  when  put  into  the  mouth.  She 
very  quickly  became  tired,  and  lay  down  to  sleep.  She 
was  given  500  c.  c.  of  milk,  as  before. 
12.00.  — She  licked  the  orderly's  hand,  and  when  her  nose  was  put 
into  some  milk  she  drank  abundantly,  and  continued  to 
be  fed  in  this  way.  Later  in  the  day  it  was  noted  that 
when  she  was  disturbed  she  observed  things  around  her, 
but,  if  left  alone,  she  slept. 

July  28,  1906. 

9.00  A.  M. — This  morning  she  appeared  more  lethargic.  The  wound 
in  the  axilla,  where  the  cannula  had  been  inserted,  was 
discharging  freely.  Temperature,  39.1°  C.  The  scratch 
reflex  was  not  satisfactory,  only  a  head  reaction  being 
obtained.  At  times  the  dog  seemed  to  be  conscious  of 
petting,  but  very  vaguely  so.  In  some  instances  threat- 
ening motions  apparently  caused  slight  cowering,  but 
usually  they  were  regarded  with  complete  indifference. 
When  left  alone  she  slept  all  the  time.  She  was  very 
sensitive  to  pain.  Sometimes  she  reacted  to  the  odor  of 
the  old  pipe.  Sounds  attracted  attention  only  when  made 
close  to  her.  She  still  regarded  with  indifference  a 
lighted  match  in  front  of  her  eyes.  She  drank  milk  only 
when  it  was  put  into  her  mouth.  After  being  examined 
she  sank  into  a  deep  stupor. 

July  29,  1906. 

9.00  A.  M. — When  a  door  near  her  was  opened  she  raised  her  head. 
She  appreciated  the  proximity  of  milk,  drinking  spon- 
taneously when  it  was  set  near  her  head.  She  gave  a 
slight  scratch  reflex.  Whistling  and  calling  caused  her 
to  raise  her  head,  but  otherwise  she  paid  no  attention. 
For  the  first  time  a  lighted  match 'near  her  head  caused 
her  to  withdraw  it.  Threatening  motions  produced  cow- 
ering and  trembling.  Petting  produced  nothing  defi- 
nite except  a  head  reflex,  as  though  she  were  going  to 
catch  a  fly. 

July  31,  1906. 

9.00  A.M. — Since  the  last  note  the  dog  was  practically  in  a  uniform 
state  of  hebetude,   although  her  physical  condition  was 


38  SURGICAL  ANEMIA  AND  RESUSCITATION 

almost     normal.       She    walked    with     very    little    un- 
sseadiness  when  examined  on  the  above  date.    Her  sense 
of  sight  was  very  feeble,  as  she  had  no  perception  of 
objects  so  close  to  her  nose  that  she  could  not  turn  aside 
quickly  enough  to  avoid  bumping  into  them  with  force. 
She  would  walk  across  the  laboratory  floor  in  a  straight 
line  until  she  hit  whatever  happened  to  be  in  her  line  of 
progress.     Then  she  would  have  her  direction  changed, 
only   to    repeat   the   performance   over   and   over   again. 
To  loud  whistling  she  made  only  a  delayed,  indifferent, 
ideationless  turning  of  her  head.     At  times  she  seemed 
to  appreciate  being  petted,  while  at  others  she  was  abso- 
lutely  indifferent,   only   a   scratch   reflex  being   brought 
forth.     On   one   occasion   she   rubbed   against    the   ob- 
server's leg,  as  if  petting  gave  her  pleasure. 
For  several  weeks  longer  improvement  of  the  mental  state  was 
so  slow  as  to  be  almost  imperceptible.     The  dog  was  utterly  listless, 
sleeping,  or  at  least  lying  down  most  of  the  time,  occasionally  walk- 
ing about  in  a  very  constricted  area,  or  standing  still  with  the  head 
lowered.     How  much  this  was  dependent  on  her  almost  total  blind- 
ness it  was  impossible  to  say,  but,  with  the  return  of  vision,  at  least 
a  vision  sufficient   for  her  purposes,   ideation  began  to  be  apparent, 
and  later  appeared  what  might  be  called,  for  lack  of  a  better  phrase,  a 
conscious  initiative,  an  acting  for  herself.     Inside  of  six  weeks,  to 
all  appearances,   her  mental  and  physical   functions  were  as  before 
her  period  of  relative  death. 

EXPERIMENT    3 

Death    from    Chloroform;    Resuscitation    Begun    3    Minutes   After 
Cessation  of  Circulation;   Total  Duration  of 
Anemia,  5  Minutes 
July  27,  1906. 

Mongrel   dog;   weight,    about   7.0   kilos.      Experiment   conducted 
as  in  Experiment  i.     Total  duration  of  anesthesia,  15  minutes. 
10. 16.15  A.  M. — Respiration  ceased. 
10.20.      — The  heart  began  to  fail  rapidly. 
10.20.15. — Circulation  ceased. 

10.23.15. — Began  to  resuscitate  in  the  usual  way,  3  minutes  after  ces- 
sation  of   circulation. 
10.25.     — The  heart  began  to  beat  again,  making  the  total  duration 
of  cessation  of  circulation  5  minutes. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  39 

10.25.40. — Spontaneous  respiration  began,  40  seconds  after  return  of 
the  circulation. 

10.27.  — Conjunctival  reflexes  were  first  noted,  2  minutes  after  re- 
turn of  the  circulation.  The  knee-jerks  returned  a  little 
later,  but  were  not  uniform  for  some  time,  although  the 
dog  rapidly  became  rather  spastic,  with  clonic  muscular 
spasms  and  continuous  barking. 

10.40.  — The  pupils  were  contracted.  On  account  of  the  struggles 
of  the  animal  the  pupillary  reflexes  were  not  satisfac- 
torily obtained. 

10.42,  — On  being  disturbed  there  was  an  ataxic  effort  to  get  up  on 
his   feet. 

10.45.  — -^^  unsuccessful,  spontaneous  effort  to  get  up  occurred. 
The  pupils  did  not  react  to  light.  There  was  no  scratch 
reflex. 

10.50.  — On  being  disturbed  the  dog  struggled  and  tried  to  get 
away.  The  breathing,  which  had  previously  been  very 
rapid  and  labored,  was  now  quiet. 

10.55.  — The  spasticity  had  diminished.  When  placed  on  the  floor 
loud  whistling  caused  the  dog  to  stand  on  his  feet  and 
move  away.  The  motion,  however,  was  of  a  semi-crawl- 
ing character,  there  being  very  little  control  of  the  front 
legs.  A  lighted  match  held  in  front  of  the  eyes  caused 
the  head  to  be  jerked  away. 
2.00.  — There  was  no  scratch  reflex.  The  knee-jerks  were  again 
somewhat  exaggerated.  The  dog  was  in  a  somnolent 
state,  paying  no  attention  to  loud  sounds.  A  lighted 
match  before  the  eyes  produced  only  a  conjunctival  re- 
flex. Warming  the  paw  to  the  point  of  slight  discom- 
fort only  caused  it  to  be  moved  away,  and  there  was 
apparently  no  evidence  of  pain  being  caused.  Warming 
the  ear  caused  only  a  muscle  reflex. 
July  28,  1906. 

9.00  A.  M. — Earlier  in  the  morning  a  feeding  through  the  stomach 
tube  was  vomited,  only  a  little  of  the  milk  being  re- 
tained. The  dog  was  found  out  of  his  box,  suffering 
severely  from  snuffles,  and  with  a  respiratory  defect,  as 
shown  by  the  slow  and  labored  respiration.  The  heart 
action  and  blood-pressure  were  of  good  quality.  The 
temperature  was  39.1°  C.  On  account  of  the  lethargic 
condition  little  was  brought  out  by  the  examination. 
He  was  indifferent  to  a  lisfhted  match  held  in  front  of 


40  SURGIC-\L  ANEMIA  AND  RESUSCITATION 

the  eyes,  hardly  more  than  a  conjunctival  reflex  being 
called  forth.  On  loud  sounds  being  made,  he  reacted 
but  slightly,  with  coordinated  muscular  movements.  To 
loud  whistling  at  any  distance  he  was  indifferent.  The 
smell  test  with  the  old  tobacco  pipe  was  negative. 
There  was  no  scratch  reflex.  Apparently  he  was  not 
conscious  of  pain.  It  was  impossible  to  make  him  an- 
gry. He  walked  normally.  On  holding  him  he  pulled 
away,  and  when  let  alone  he  at  once  went  to  a  corner 
and  lay  down.  To  threatening  motions  with  a  broom 
he  was  absolutely  indifferent. 

July  29,  1906. 

9.00  A.  M. — When  the  observer  came  into  the  room  the  dog  re- 
garded his  entrance  with  ordinary  intelligence.  Hear- 
ing and  vision  were  apparently  good.  An  error  of 
judgment  was  made  on  the  part  of  the  observer  in 
making  threatening  motions  before  conducting  the  rest 
of  the  examination.  As  a  result  the  dog  cowered 
and  walked  into  a  distant  corner  under  a  table,  and  the 
subsequent  examination  was  not  satisfactory,  on  account 
of  his  fear.  Attempting  to  pull  him  out  of  the  corner 
made  him  snarl,  but  he  did  not  attempt  to  attack  the 
observer.  After  prolonged  petting,  he  finally  wagged 
his  tail,  but  he  still  seemed  cowed.  He  would  not  drink 
milk  when  it  was  put  into  his  mouth.  He  reacted  poorly 
to  the  smell  of  the  tobacco  pipe.  There  was  no  scratch 
reflex. 

July  30,  1906. 

9.00  A.  M. — The  dog  refused  milk,  but  ate  an  abundance  of  meat.  He 
responded  normally  to  petting  and  threatening.  All  his 
muscular  movements  seemed  normal.  In  some  un- 
known way  he  escaped  from  the  laboratory  to  the  street, 
and  was  chased  by  the  orderly  for  half  a  mile  before  he 
was  caught.  While  escaping  he  showed  all  evidences  of 
normal  canine  intelligence  in  eluding  capture.  In  about 
two  hours  he  escaped  a  second  time,  probably  through 
an  open  first  floor  window,  and  reached  the  street  by  a 
very  devious  route.  He  was  seen  no  more,  but  there  is 
no  doubt  but  that  he  was  well  able  to  take  care  of 
himself. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  41 

EXPERIMENT    4 

Death    from    Chloroform;    Resuscitation    Begun    6   Minutes   After 

Cessation  of  Circulation;   Total  Duration  of 

Anemia,  83^  Minutes 

July,  1906. 

Young  fox  terrier ;  weight,  7.3  kilos ;  condition,  good.     Experi- 
ment conducted  as  in  Experiment  i.     Total  duration  of  anesthesia,  15 

minutes. 

9.57  A.  M. — Respiration  ceased. 

9.58.        — Circulation  ceased. 

9.59.30.  — Several  weak  respiratory  movements  occurred,  and  the 
heart  beat  feebly  again  for  about  10  seconds.  The  ac- 
tion was  too  weak  to  produce  a  palpable  pulse  in  the 
carotids. 

10.04.  — Began  to  resuscitate,  6  minutes  after  cessation  of  circu- 
lation. 

10.06.30. — The  heart  began  to  beat  again,  making  the  total  duration 
of  cessation  of  circulation  8^  minutes. 

10.09.  — Spontaneous  respiration  began,  2^  minutes  after  return 
of  the   circulation. 

10.20.     — The  respiration  was  regular. 

10.23.  — The  conjunctival  reflex  was  first  obtained  and  normal 
spontaneous  winking  noted,  163/2  minutes  after  return 
of  the  circulation.  The  fore  leg  reflex  was  first  ob- 
tained 3^  minute  later,  and  was  more  marked  in  the 
right  leg.  (Note. — This  was  the  first  experiment  in 
which  the  leg  reflex  was  obtained  in  a  fore  leg  before 
being  obtained  in  a  hind  leg.)  The  knee-jerks  ap- 
peared somewhat  later,  and  first  in  the  right  leg. 

11.26.  — The  right  knee-jerk  was  strong,  the  left  weak.  The  dog 
began  to  utter  an  inarticulate  cry.  Rectal  temperature, 
36.1°  C. 

11.32.  — The  fore  legs  began  to  stiffen.  The  hind  legs  were  still 
relaxed. 

11.45.  — The  hind  legs  were  considerably  more  spastic.  There  was 
no  definite  pupillary  reflex.    Temperature,  36.6°. 

2.30,  — Temperature,  36.1°.  The  dog  was  still  unconscious,  with 
no  indication  of  even  incoordinated  muscular  movements. 
The  hind  legs  were  very  spastic,  while  the  fore  legs 
had  become  flaccid.  The  knee-jerks  were  exaggerated. 
There  v/as   no    scratch   reflex.     The   pupils   were   con- 


42  SURGia\L  AXEML\  AXD  RESUSCITATION 

tracted,  but  the  light  reflex  could  not  be  obtained  with 
certainty.  The  dog  both  vomited  and  defecated. 
4.30.  — A  condition  of  complete  coma  was  present.  Xo  muscular 
movement  had  been  made,  and  the  spastic  condition  had 
disappeared.  Vomiting  occurred  again.  The  morning 
of  the  succeeding  day  the  dog  was  found  dead,  and  had 
evidently  died  early  in  the  preceding  evening,  as  the 
body  was  much  distended  with  gas  from  an  infection 
with  Bacillus  aero  genes  capsnlatus. 
Autopsy. — The  heart  had  stopped  in  systole.  There  was 
no  evidence  of  any  injury  of  the  thorax  or  its  contents. 
In  the  heart  a  post-mortem  clot  was  found  in  the  light 
side,  while  in  the  left  a  small,  firm,  ante-mortem  clot 
was  entangled  in  the  auriculoventricular  valve.  It  was 
not  large  enough,  however,  to  interfere  with  the  circu- 
lation. The  lungs  were  moderately  congested — on  the 
left  side  hypostatically  so.  Otherwise  the  viscera  were 
negative. 

EXPERIMENT    5 

Death    from    Chloroform;    Resuscitation    Begun    9    Minutes    After 
Cessation   of  Circulation ;   Total  Duration   of 

July,  1906.  Anemia,  14  Minutes. 

Mongrel  dog;  weight,  about  5  kilos.       Experiment  conducted  as 

in  Experiment  i.     Total  duration  of  anesthesia,  about  20  minutes. 

11.28.30.  A.  M. — Respiration  ceased. 

11.28.40. — Circulation  ceased. 

11.37.40. — Began  to  resuscitate,  9  minutes  after  cessation  of  circula- 
tion. Ringer's  solution  was  substituted  for  normal  saline 
solution,  and  only  0.5  c.  c.  of  adrenalin  chlorid  solution 
was  used. 

11.42.  — The  heart  began  to  beat  again,  making  the  total  duration 
of  cessation  of   circulation   14  minutes. 

11.46.  — Spontaneous  respiration  began,  4  minutes  after  return  of 
the  circulation. 

11.52.      — Stopped  giving   artificial   respiration. 

11.56.  — The  knee-jerk  was  obtained  in  the  left  hind  leg,  14  min- 
utes after  return  of  the  circulation. 

11.56.30. — The  knee-jerk  was  obtained  in  the  right  hind  leg,  and  was 
faintly  present  in  the  fore  legs. 

11.58,  — On  touching  the  left  eye  the  conjunctival  reflex  was  ob- 
tained,  16  minutes  after  return  of  the  circulation,   and 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM       43 

in  the  right  eye  a  little  later.  If  the  nose  were  pinched 
the  right  fore  leg  was  moved.  The  pupils  had  become 
very  much  contracted.    Temperature,  36.1°  C.  by  rectum. 

1.45  p.  M. — Temperature,  36.1°.  The  dog  was  generally  more  spastic. 
The  pupillary  reaction  to  light  was  distinct,  although 
slight  and  delayed,  less  than  2  hours  after  return  of  the 
circulation.  Respirations  were  somewhat  groaning  in 
character.  Voluntary  movements  of  the  legs,  such  as 
occur  in  the  early  stages  of  ether  anesthesia,  were  made, 
and  at  times  the  head  was  raised,  as  if  in  an  attempt  to 
rise.  Warming  the  paw  to  a  moderate  degree  only 
caused  withdrawal  of  the  limb,  and  there  was  apparently 
no  consciousness  of  pain.     Temperature,  37.8°. 

5.30.        — Temperature,  39.0°.     The  condition  was  about  the  same. 

10.00.  — The  dog  was  found  out  of  his  box  on  the  floor.  He  made 
unconscious  propulsive  movements  of  the  legs,  and  at 
times  raised  his  forelegs,  as  if  trying  to  get  up.  The 
latter  movements  did  not  seem  to  be  purposeful.  There 
was  a  general  spastic  condition  of  the  muscles,  and  the 
knee-jerks  were  exaggerated.  The  pupils  reacted,  al- 
though slowly.  There  was  no  evidence  of  perception  of 
pain,  and  the  dog  neither  saw  nor  heard.  Disturbing  by 
touching  evoked  only  reflex  movements.  The  next  morn- 
ing the  dog  was  found  on  the  floor  in  deep  stupor,  with 
thready  pulse,  quiet  respiration,  and  temperature  of 
39.0°.  He  started  when  touched  at  any  point,  although 
the  knee-jerks  were  not  so  exaggerated,  and  the  spastic 
condition  had  disappeared.  He  was  oblivious  of  stimu- 
lation through  any  of  the  special  senses.  There  was  no 
scratch  reflex.  Death  occurred  at  about  11.30  A.  M.  Du- 
ration of  recovered  animation,  24  hours. 

EXPERIMENT    6 

Death  from  Chloroform;  Resuscitation  Begun   sV^  Minutes  After 
Cessation  of  Circulation;   Total  Duration   of 
Anemia,  7^  Minutes 
July,,  1906. 

Mongrel  dog;  weight,  about  8  kilos.     Experiment  conducted  as  in 
Experiment  i. 

lo.ii  A.  M. — Respiration  ceased. 

10,12.  — The  heart  almost  stopped,  and  then  beat  more  strongly. 
The  pulse  was  barely  perceptible. 


44  SURGICAL  ANEMLA.  AND  RESUSCITATION 

10.14.  — The  heart  sounds  ceased,  and  the  pulse  was  no  longer  per- 
ceptible. 

10.19.30. — Began  to  resuscitate,  5^  minutes  after  cessation  of  the  cir- 
culation. 

10.21.30. — The  heart  began  to  beat  again,  making  the  total  duration 
of  cessation  of  circulation  7I/2  minutes. 

10.30.      — Rectal  temperature,  37.0°  C. 

10.35.30. — Spontaneous  respiration  began,  14  minutes  after  return  of 
the  circulation. 

10.38.      — Stopped  giving  artificial  respiration. 

10.50.  — The  knee-jerks  were  obtained,  most  marked  in  the  right 

leg,  283^  minutes  after  return  of  the  circulation. 

10.51.  — A  faint  conjunctival  reflex  was  obtained  on  touching  the 

eyes,  29^  minutes  after  return  of  the  circulation.  The 
pupils  were  contracted. 

10.55.  — Both  pupils  reacted  to  light,  33^^  minutes  after  return  of 
the   circulation,   but  there  was  no  winking. 

10.57.30. — Faint  spontaneous  winking  appeared,  36  minutes  after  re- 
turn of  the  circulation.  The  knee-jerks  had  become 
very  much  exaggerated.  There  was  a  general  return  of 
muscle  tone. 

11.22.      — Inarticulate  barking  sounds  were  made. 

11.40.      — The  muscles  were  generally  spastic. 

12.00.  — Movements  of  the  leg,  such  as  occur  in  the  early  stages 
of  anesthesia,  were  begun. 

3.35.        —Temperature,  37.7°  C. 

5.00.  — Temperature,  38.0°  C.  Periods  of  restlessness,  with  mov- 
ing about  in  the  box,  and  respiratory  cries  alternating 
with  periods  of  quiet.  There  was  no  response  to  a  light 
moved  in  front  of  the  eyes,  nor  to  loud  sounds.  If 
touched  the  dog  usually  moved.  There  was  no  evidence 
of  pain  being  felt.  Even  with  frequent  attempts  the 
scratch  reflex  could  not  be  obtained. 

10.30.  — The  condition  was  the  same,  except  that  there  was  more 
restlessness  and  more  spasticity.  The  next  morning  the 
dog  was  found  dead  and  stiff.  The  autopsy  revealed  no 
gross  lesions. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  45 


EXPERIMENT    7 

Death  from  Asphyxiation;  Resuscitation  Begun  4^  Minutes  After 

Cessation  of  Circulation;  Total  Duration  of 

Anemia,  5^  Minutes 

July,  1906. 

Mongrel  collie  dog;  weight,  about  9.2  kilos.     Ether  was  used  for 

carrying  out  the  operative  technique  in  the  usual  way.     The  trachea 

was  exposed  by  a  small  incision  and  clamped  to  produce  asphyxia. 

10.42.40 — The  heart  almost  stopped  beating,  only  to  start  again  with 
a  distinct  pulse  perceptible. 

10.45.      — Respiration  ceased. 

10.45.15. — Circulation  finally  ceased. 

10.49.30. — Began  to  resuscitate,  4^  minutes  after  cessation  of  cir- 
culation. 

10.51.  — The  heart  began  to  beat  again,  making  the  total  cessation 
of  circulation  5^  minutes. 

11.00.      — Stopped  the  artificial  respiration. 

11.03.30. — On  touching  the  right  eye  the  conjunctival  reflex  was  ob- 
tained, 12^  minutes  after  cessation  of  the  circulation, 
and  Yi  minute  later  it  was  obtained  in  the  left  eye. 

11.05.  — I^  the  right  eye  the  light  reflex  was  good,  but  in  the  left 
it  was  faint,  I4>4  minutes  after  cessation  of  the  circula- 
tion. The  right  pupil  was  contracted,  while  the  left  was 
dilated.  The  hind  legs  were  drawn  up,  but  there  were 
no  knee-jerks. 

1 1. 15.  — The  knee-jerks  were  obtained,  24^^   minutes   after  cessa- 

tion of  the  circulation. 

11. 16.  — An  inarticulate  crying  began. 

11.45.  — For  the  first  time  spontaneous  muscular  movements  were 
noted.  There  was  no  scratch  reflex,  and  no  conscious- 
ness of  light  or  sound.    Temperature,  37.9°  C.  by  rectum. 

i.oo.        — Temperature,  38.5°. 

4.30.        — Temperature,  39.6°. 

5.00.  — The  dog  was  lying  quietly  in  an  extremely  stupid  condi- 
tion, but  not  sleeping.  The  striking  of  a  match  in  front 
of  his  eyes  caused  him  to  raise  his  head  and  cock  an  ear 
just  a  little,  but  the  pupils  did  not  change.  He  seemed 
to  be  just  a  little  conscious  of  pain.  There  was  no 
scratch  reflex.    The  hind  legs  were  rather  spastic. 

5.30.      — Temperature,  40.1°. 


46  .     SURGICAL  ANEMIA  AND  RESUSCITATION 

10.30  p.  M. — The  dog  was  entirely  unconscious.     His  eyeballs  were 
turned  down  and  half  covered  by  the  conjunctivae.     The 
pupils   were  dilated  and  gave  but   a   faint  light   reflex. 
The  knee-jerks  were  active.     Only  the  hind  legs  were 
slightly  spastic.     On  pinching  the  paw  the  leg  was  with- 
drawn.     On    warming  the   ear   both   the   head   and   the 
body  were  moved  slightly.     The  special  senses  were  ab- 
sent.    Temperature,  39.2°.     On  inserting  the  thermome- 
ter in  the  rectum  the  legs  were  moved. 
On  the  second  day  the  dog  was  still  in  a  deep  stupor,  and  evi- 
dently very  ill.     No  satisfactory  results  were  obtained  in  making  the 
usual  examination.     On  the  third  day  it  was  found  that  the  dog  was 
infected,  and  he  was  killed  with  chloroform. 

EXPERIMENT    8 

Death  from   Chloroform;  Resuscitation  Begun  3^^   Minutes  After 
Cessation  of  .Circulation;  Total  Duration  of 
Anemia,  5  Minutes 
July,  1906. 

Male  mongrel  collie  puppy;  weight,  3.6  kilos.     Experiment  con- 
ducted as  in  Experiment  i.    Total  duration  of  anesthesia,  up  to  cessa- 
tion of  respiration,  about  15  minutes. 
11.05.45  A.M. — Respiration  ceased. 
11.09.      — Circulation  ceased. 

1 1. 12.30. — Began  to  resuscitate,  3}4  minutes  after  cessation  of  cir- 
culation. 

1 1. 16.  — The   heart  began   to  beat,   making  the   total   cessation   of 

circulation  5  minutes. 

11. 17.  — Spontaneous   respiration  began. 

11.26.  — Stopped  giving  artificial  respiration.  From  the  first  the 
blood-pressure  continued  to  be  good,  and  the  spontane- 
ous respiration  was  well  maintained.  After  stopping 
artificial  respiration  the  latter  was  normal  for  20  min- 
utes, then  began  gradually  to  fail.  Artificial  respi- 
ration was  resumed  for  a  while,  but  without  effect.  Up 
to  this  time  none  of  the  reflexes  had  reappeared  (knee- 
jerks,  muscle,  or  eye),  and  the  muscles  were  entirely 
flaccid.  At  about  11.50  respiration  failed  altogether. 
On  rapidly  opening  the  chest  the  heart  was  found  to  be 
still  beating,  and  continued  to  beat  rhythmically  for  15 
minutes,    even   after   both   ventricles   had    been   incised. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  47 

The  lungs  appeared  to  be  normal.  The  abdomen  con- 
tained a  sHght  excess  of  fluid.  Portions  of  the  brain 
were  placed  in  alcohol  about  15  minutes  after  opening 
the  thorax,  while  there  was  still  some  circulation. 


EXPERIMENT    9 

Death  from   Chloroform;  Resuscitation  Begun  35^   Minutes  After 

Cessation  of  Circulation;  Total  Duration  of 

Anemia,  53^  Minutes 

December  22,  1906. 

Mongrel  dog;  weight,  about  8.0  kilos.     Besides  the  usual  arrange- 
ments a  cannula  was  inserted  in  a  femoral  artery  and  connected  with 

a  mercury  manometer,  so  that  the  blood-pressure  could  be  recorded 

on  a  smoked  drum. 

12.10  p.  M. — Control  on  drum. 

12.13.      — Vasomotor   action   elicited.      Control. 

12.17.      — Forced  the  chloroform. 

12.19.30. — Respiration  ceased. 

12.20.  — The  heart  stopped  beating,  but  after  a  few  seconds  began 
to  beat  again. 

12.22.      — Circulation  ceased.  ■ 

12.25.30. — Began  to  resuscitate,  3}^  minutes  after  cessation  of  circu- 
lation. Only  two  thirds  of  a  cubic  centimeter  of  adrena- 
lin chlorid  solution  was  injected. 

12.27.30. — The  heart  began  to  beat  again,  making  the  total  duration 
of  cessation  of  circulation  5^^  minutes. 

12.29.30. — A  single  respiratory  gasp  occurred.  There  was  no  vaso- 
motor reaction  on  stimulation. 

12.30.30. — There  were  several  respiratory  gasps,  but  no  vasomotor 
reaction. 

12.31.30. — Respiration  began  steadily,  and  immediately  after  a  distinct 
vasomotor  reaction  was  obtained. 

12.38.     — Control. 

12.40.  — There  was  a  feeble  conjunctival  reaction  to  touching  the 
eyeball.  The  knee-jerks  were  first  obtained,  and  were 
somewhat  exaggerated. 

12.43.      — There  was   faint,  spontaneous  winking. 

12.45.      — There  was  a  faint  pupillary  reaction  to  strong  light. 

12.50.  — There  was  a  general  spastic  condition  of  the  muscles. 
The  respiratory  movements  were  labored. 

12.55.     — Slight  spontaneous  movements  of  the  hind  legs  occurred. 


48  SURGICAL  ANEMIA  AND  RESUSCITATION 

12.59.  — On  disturbing  the  dog  he  made  purposeful  muscular 
movements,  and  the  head  was  raised,  as  if  he  wanted  to 
rise.  On  warming  the  ear  he  showed  definite  signs  of 
consciousness. 

I.OO.  — There  was  a  faint  response  to  auditory  stimuli,  respiration 
stopped  for  a  moment,  the  eyes  opened,  and  the  ears 
pricked  up.  To  stimulation  with  light  only  winking  was 
obtained. 

1.30.  — The  dog  tried  to  rise  and  move  forward.  The  spasticity 
was  distinctly  less.  There  was  no  indication  of  con- 
scious vision. 

1.42.        — The  dog  tried  to  walk,  but  was  too  ataxic  to  succeed. - 

2.00.        — Condition  about  the  same. 

4.36.  — There  was  the  same  degree  of  purely  reflex  visual  action 
and  also  auditory  reaction,  which,  as  before,  had  the 
appearance  of  consciousness  merely  rather  than  of 
seeing  or  hearing.  More  spasticity  was  present.  When 
first  seen  the  appearance  was  more  stupid  than  at  2.00, 
but,  while  being  observed,  there  suddenly  started  a  vio- 
lent dyspnea,  in  place  of  the  normal  respiration,  and 
several  unsuccessful  attempts  were  made  to  crawl  for- 
ward. This  lasted  for  about  7  minutes,  gradually  sub- 
sided to  quiet  breathing  for  about  a  minute,  and  then 
began  again.  The  second  period  of  dyspnea  lasted  for 
about  3  minutes,  to  be  followed  by  a  short  period  of 
almost  complete  apnea,  another  minute  of  dyspnea,  half 
a  minute  of  apnea,  and  two  or  three  more  times  the 
forward  propulsive  efforts  were  made.  This  arrhyth- 
mic, Cheyne-Stokes  type  of  respiration  continued  as 
long  as  this  period  of  observation  lasted,  about  40 
minutes.  When  the  dog  was  returned  to  his  bed  he 
became  somewhat  quieter. 

December  23,  1906. 

10.00 A.M. — On  approaching  the  dog  he  raised  his  head  toward  the 
observer  with  some  appearance  of  intelligence,  but  he 
immediately  relapsed  into  his  stupid  state.  It  is  a  ques- 
tion if  any  ideation  was  conveyed.  The  flash  of  a  match 
repeated  in  front  of  his  eyes  evoked  only  a  faint  con- 
junctival reflex.  The  signs  of  more  conscious  reaction 
were  apparent,  although  not  more  markedly  so  than  on 
the  preceding  day.  The  pupils  were  very  much  di- 
lated, reacting  to  light  both  directly  and  indirectly,  i.e., 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM  49 

stimulation  of  one  eye  only  would  cause  the  other  to  re- 
act also.  Appreciation  of  pain  was  very  doubtful.  The 
knee-jerks  were  exaggerated,  although  there  was  less 
plasticity  than  on  the  preceding  day.  When  placed  on  his 
feet,  he  was  able  to  stand,  although  on  walking  he  was 
very  ataxic,  largely  because  of  paralysis  of  the  right 
hind  leg,  the  result  of  the  operative  procedures. 
There  was  no  patellar  reflex,  even  after  repeated  tests. 
Petting  was  submitted  to  without  any  appearance  of 
ideation,  while  there  was  absolute  indifference  to  threat- 
ening. Water  was  refused  when  placed  in  his  mouth. 
He  was  etherized,  and  a  portion  of  the  brain  at  once 
transferred  to  96  per  cent,  alcohol. 

EXPERIMENT    10 

Death    from    Chloroform;    Resuscitation    Begun    5    Minutes    After 

Cessation  of  Circulation ;   Total  Duration  of 

Anemia,  10  Minutes 

December,  1906. 

Dog;   weight   not   noted.     Experiment   conducted   as   in   Experi- 
ment I. 

9.55  A.  M. — Began  to  anesthetize  with  ether. 

10.10.      — Changed  to  lethal  dose  of  chloroform. 

10.12.      — Respiration  ceased. 

10.14.40. — Circulation  ceased. 

10.19.30. — Began  to  resuscitate,  5  minutes  after  cessation  of  circula- 
lation.  Rather  violent  massage  was  employed,  and  three 
doses  of  adrenalin  of  two  cubic  centimeters  each  were 
given. 

10.24.20. — The  heart  began  to  beat,  making  the  total  cessation  of  cir- 
culation 10  minutes. 

10.29.30. — First  indications  of  returning  respiration  were  noted. 

10.32.20. — Faint  spontaneous  respiration  began. 

10.40.      — Stopped  giving  artificial  respiration.   ' 

10.45.      — Knee-jerks  were  obtained  in  the  right  hind  leg. 

10.50.  — An  occasional  conjunctival  reflex  could  be  obtained  in  the 
right  eye.     The  knee-jerks  were  exaggerated. 

10.53.      — The   conjunctival   reflex   was   obtained   in  the   left   eye. 

11.00.      — There  were  partially  spontaneous  conjunctival  reflexes. 

11.07.  — The  pupils  had  been  contracting  slowly,  and  were  about 
one-half  normal  size.     There  was  no  pupillary  reflex  to 


so 


SURGICAL  ANEMIA  AND  RESUSCITATION 


TABLE  I— SERIES   I 
The  Time  of  the  Respiratory  and  Circulatory  Changes 


Duration  of 

Time  from 

Recurrence  of 

Beginning  of 

Time  from 

Inefficient 

No.  OF 

Administra- 

Respiratory 

Heart  Beats 

Duration 

Experi- 

tion of  Chloro- 

to Cardiac 

After  Appar- 

of Total 

Results 

ment 

form  to  Res- 
piratory 
Failure 

Failure 

ently  Com- 
plete 
Failure  1 

Anemia 

12 

4f 

3^ 

0 

3 

Killed  after  i  hour. 

lo 

4^ 

i3^ 

0 

4^ 

Killed  after  i  hour. 

17 

3 

0 

4M 

Died,  53  minutes. 

3 

iJ4 

4 

0 

5 

Recovery. 

22 

2 

3 

IM 

5^(6-/2) 

Recovery. 

8 

2j^ 

K 

2 

5K(7H) 

Killed,  24  hours. 

26 

2 

M 

0 

sM 

Killed  on  4th  day;  sec- 
ondary infection. 

13 

2 

6 

2 

6(8) 

Killed  after  i  hour. 

2 

2^        . 

I 

^ 

6(61^) 

Recovery. 

23 

2% 

iM 

0 

6A 

Died,  24  hours. 

29 

5. 
6 

3 

0 

6M 

Recovery. 

25 

I^ 

4^ 

0 

7 

Died  after  30-40  hours. 

7 

3^ 

0 

7 

Died,  34  minutes. 

II 

7A 

^ 

0 

73^ 

Died,  15-20  hours. 

6 

3 

3 

0 

7^ 

Died,  12-20  hours. 

27 

2-i'2 

22 

0 

7K 

Recovery. 

20 

2M 

iM 

0 

8 

Died,  10-20  hours. 

28 

3^ 

iK 

0 

8^ 

Died,  12-20  hours. 

18 

2 

0 

8M 

Died,  63  minutes. 

4 

4 

I 

M 

83^  (8K) 

Died,  about  12  hours. 

19 

2M 

If 

0 

8A 

Died,  about  20  hours. 

14 

2 

I 

0 

8>^ 

Died,  30-40  hours;  dis- 
seminated broncho- 
pneumonia. 

24 

4^ 

3 

0 

8J^ 

Died,  23  hours. 

I 

6M 

0 

9K 

Died,  II  hours. 

9 

2 

2% 

0 

9% 

Killed,  I  hour. 

IS 

3^ 

y^ 

0 

9M 

Died,  about  18  hours. 

16 

0 

10 

Died,  10-18  hours. 

30 

11^2 

3 

0 

123^ 

Died,  about  23^  hours. 

S 

M 

0 

13M 

Died,  24  hours. 

21 

2 

3 

0 

14 

Died,  40  minutes. 

^This  column  refers  to  the  spontaneous  recurrence  of  the  heart  sounds  in  five 
cases  from  one-third  to  one  and  a  half  minutes  after  they  had  entirely  ceased. 
As  the  extent  of  the  circulatory  recovery  could  not  be  exactly  estimated,  though 
usually  it  was  not  sufficient  to  produce  a  palpable  pulse,  in  the  next  column  the 
duration  of  the  total  period  without  any  evidence  of  cardiac  activity  is  given 
first,  while  the  figures  in  parentheses  include  the  partial  recovery. 

2  Asphyxiated  dog. 

'  Synchronous. 

Note. — Time  is  expressed  in  minutes,  and  blood-pressure  in  millimeters  of 
mercury. 


ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM 


SI 


light.  The  knee-jerks  were  very  much  exaggerated. 
There  was  only  moderate  resistance  to  passive  motion 
of  the  legs — to  flexion  more  than  to  extension. 

1 1. 12.  — The  fore  and  hind  legs  were  held  in  rigid  extension,  with 
occasional  tremors  occurring. 

II. 15.  — The  right  pupil  was  more  contracted  than  the  left,  and 
gave  no  reflex. 

11.40.  — There  was  still  no  pupillary  reaction  to  light,  although  the 
pupils  were  of  equal  size  by  this  time.  The  respiration 
was  normal,  and  the  heai't  action  and  pulse  were 
of  good  character.  The  cerebral  cortex  was  exposed 
and  stimulated  by  an  induced  current  in  various  places 
around  the  motor  area.  No  muscular  contractions  re- 
sulted. Before  the  heart  stopped  beating  the  brain  was 
transferred  to  alcohol. 


TABLE  II— SERIES   I 

Ten  Cases  in  Which  the  Total  Anemia  Lasted  Seven  and  One-Half  or  More  Minutes 


Number  of 
Experiment 

Mode  of  Death 

Total  Duration 
of  Anemia ' 

Results 

28 
19 

Ether 
Asphyxia 

73^  minutes 
83^  minutes 

Presumptive  recovery; 

killed  after  24  hours. 
Killed  after  6  hours. 

3^ 

Chloroform 

93^  minutes 

Died  after  20  hours. 

37 

Chloroform 

g}/^  minutes 

Died  after  20  hours. 

48 

Asphyxia 

1 2      minutes 

Died  after  sH  hours. 

39 

Chloroform 

133/2  minutes 

Died  after  15  hours. 

41 

Chloroform 

15      minutes 

Died  after  15  hours. 

30 

Ether 

163^  minutes 

Died  after  33^^  hours. 

43 

Chloroform 

24      minutes 

Died  after  4^^  hours. 

49 

Chloroform 

32      minutes 

Died  after  27  minutes. 

^  The  figures  in  this  column  include  the  time  spent  in  resuscitating. 


52 


SURGICAL  ANEMIA  AND  RESUSCITATION 


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ANEMIA  OF  THE  CENTRAL  NERVOUS  SYSTEM 


S3 


TABLE  IV— SERIES  I 

The  Time  of  Return  of  the  Reflexes  After  Restoration  of  the  Circulation 


No.    OF 

Duration 

Respira- 

Corneal 

Light 

Cutaneous 

Experiment 

of 
Anemia 

tion 

Reflex 

Winking 

Reflex 

Knee-Jerlj 

Reflex 
(First) 

12 

3 

2 

A% 

5 

38 

16 

_ 

lO 

4K 

1% 

10 

lo3^ 

i83^ 

10 

13M 

17 

A% 

2H 

20 

25 

0 

0 

0 

3 

S 

% 

2 

1 

io3€ 

2 

— 

22 

S>€ 

iM 

1 

^sVi 

128 

17 

23 

8 

5^ 

2 

13^ 

16M 

i8>^ 

12 

26 

S^/i 

— 

12K 

— 

14^ 

243^ 

— 

13 

6 

7A 

1 

19 

2 

35 

39 

2 

6 

M 

loM 

13 

40 

m 

25 

23 

6^ 

2 

10^ 

193^ 

3 

313^ 

32^ 

29 

6K 

M 

sK 

7H 

94 

iiK 

17^ 

7 

7 

I 

0 

0 

0 

0 

0 

25 

7 

2,V 

1 

Under  i 

29 

Under  15 

Under  15 

II 

7^ 

4M 

17 

23 

34 

17 

34 

6 

73^ 

14 

293^ 

36 

333^ 

28^ 

— 

27 

7^ 

2 

123^ 

20^i 

533^ 

143^ 

24H 

20 

8 

3 

21 

1 

0 

21 

66 

28 

8^ 

iH 

i7t 

34 

68 

1 

42 

18 

8M 

2% 

20 

25 

0 

0 

0 

4 

8M 

23^ 

1 

18K 

0 

233^ 

iZV2 

19 

Sr? 

I 

IS 

35 

62 

17 

60 

14 

83^ 

i34 

1 

i83^ 

0 

17 

— 

24 

m 

iH 

14^2 

38 

3 

1 

S3 

I 

qH 

43i 

6x3^ 

1 

983-^ 

74^ 

9 

9% 

8 

2S 

35 

2 

20% 

— 

IS 

9^ 

i3^ 

16 

34 

0 

14 

49 

16 

10 

6 

28 

38 

3 

28 

— 

30 

12^ 

2M 

I2i.i 

23/4 

32 

25M 

28M 

5 

I3H 

4 

16 

16 

60  + 

14 

16 

21 

14 

3 

0 

0 

0 

0 

0 

^  Recurred;  exact  time  not  noted. 
^  Insufficient  time. 
^  Did  not  return  under  observation. 
Note. — Time  is  expressed  in  minutes. 


CONCLUSIONS 

I.  In  dogs  lightly  anesthetized  by  ether  and  then  killed 
quickly  by  chloroform  the  average  limit  of  total  cerebral  ane- 
mia, estimated  from  cessation  of  the  heart  sounds  to  return  of 
circulation,  which  admits  of  recovery,  is  between  six  and  seven 
minutes.     The  ulterior  limit  appears  to  be  under  ten  minutes, 


54  SURGICAL  ANEMIA  AND  RESUSCITATION 

hitherto  stated  as  the  most  conservative  figure,  and  any  recov- 
ery after  more  than  seven  and  one-half  minutes  of  anemia 
would  be  exceptional. 

2.  Further  experience  with  the  resuscitation  of  animals 
killed  by  anesthesia  and  by  asphyxia,  embracing  numerous  un- 
recorded experiments,  as  well  as  those  forming  the  basis  of 
this  chapter,  establishes  the  former  conclusion  of  the  authors, 
viz.,  that  the  procedures  detailed  afford  a  reliable  method  of 
resuscitation  within  its  limitations,  and  one  uniformly  success- 
ful within  the  limits  compatible  with  the  recovery  of  the  cen- 
tral nervous  system. 


CHAPTER  II 

ANEMIA   OF  THE   CENTRAL  NERVOUS   SYSTEM  :   CLINICAL  OBSER- 
VATIONS.      CEREBRAL   ANEMIA    THROUGH    LIGATION 
OF    THE    COMMON    CAROTID   ARTERIES 

GENERAL  CONSIDERATIONS 

Although  the  blood  supply  of  the  brain  is  better  safe- 
guarded than  is  that  of  any  other  part  of  the  body,  experience 
in  ligating  the  common  carotid  arteries  in  man  has  shown  that 
harmful  cerebral  anemia  may  result. 

The  brain  of  man,  being  a  mesial  and  symmetrical  organ, 
has  two  sets  of  arteries  from  which  its  blood  supply  is  de- 
rived, each  set  consisting  of  (i)  the  common  carotid,  (2)  the 
vertebral,  (3)  the  profunda  cervicis,  and  (4)  the  inferior 
thyroid.  The  common  carotid  and  the  vertebral  artery  of 
either  side  of  the  head  furnish  the  main  blood  supply  and  con- 
nect with  the  arteries  of  the  opposite  side  through  the  circle 
of  Willis.  The  profunda  cervicis  arises  actually  from  the 
superior  intercostal,  but  so  close  to  the  origin  of  the  latter  that 
it  may  practically  be  said  to  arise  from  the  subclavian,  distal 
to  the  origin  of  the  vertebral;  it  connects  with  the  princeps 
cervicis,  and  through  it  with  the  occipital,  the  last-named  being 
a  branch  of  the  external  carotid.  The  inferior  thyroid  arises 
from  the  thyroid  axis  on  the  subclavian  (also  distal  to  the 
origin  of  the  vertebral),  connects  with  the  superior  thyroid, 
and  the  latter  with  the  external  carotid  at  its  point  of  origin 

55 


56  SURGICAL  ANEMIA  AND  RESUSCITATION 

with  the  common  carotid.  However,  as  it  also  connects  with 
the  inferior  thyroid  of  the  opposite  side,  it  would  be  less  effi- 
cient than  the  profunda  cervicis  as  a  path  of  collateral  circula- 
tion on  account  of  its  stream  being  divided. 

From  the  anatomic  relationships  it  necessarily  follows  that 
ligation  of  the  innominate  artery  would  shut  off  entirely  direct 
circulation  from  the  right  side  of  the  brain.  Likewise  ligation 
of  the  common  carotid  and  of  the  subclavian  proximal  to  the 
origin  of  the  vertebral  from  the  subclavian  would  completely 
shut  off  direct  cerebral  circulation  on  the  side  on  which  the 
ligation  was  done. 

If  the  common  carotids  and  the  vertebral  arteries  of  both 
sides  are  ligated  the  remainder  of  the  collateral  vessels  must 
take  up  the  burden,  a  burden  which,  for  practical  purposes,  is 
beyond  their  capacity.  It  is  almost  incredible  that  an  indi- 
vidual could  live  for  any  length  of  time  after  such  ligation,  but, 
in  the  "Science  and  Art  of  Surgery,"  Erichsen  mentions  a 
case  of  Davy's  in  which  life  was  maintained  for  "a  consider- 
able time." 

In  ligating  either  common  carotid  artery  success  may  de- 
pend on  the  patency  of  the  circle  of  Willis.  While  its  absence 
must  be  extremely  rare,  Derby  describes  a  case  in  which  hemi- 
plegia followed  ligation,  and  at  the  autopsy  the  circle  of 
Willis  was  found  actually  to  be  absent. 

Granting  that  the  circulation  through  the  four  major  ar- 
teries is  alone  efficient  to  maintain  the  life  of  the  brain,  and 
that  ligation  of  one  common  carotid  leaves  the  three  other  ves- 
sels open,  still  it  by  no  means  follows  that  only  one-fourth  of 
the  blood  supply  is  cut  off,  since  the  common  carotids  are  much 
larger  than  the  vertebrals.  Consequently  it  is  not  strange  that 
this  interference  may  cause  harm. 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES 


57 


ANALYSIS  FROM  THE  LITERATURE  OF  FIVE  HUNDRED 
CASES   OF  LIGATION   OF  THE   COMMON 
CAROTID     ARTERY 

-In  order  to  ascertain  with  reasonable  accuracy  how  fre- 
quently injury  of  the  brain  due  to  anemia  has  followed  liga- 
tion of  the  common  carotid  artery,  five  hundred  cases  were 
chosen  at  random  from  reliable  sources  in  the  literature  of  the 
subject.  Many  cases  were  omitted  in  which  serious  injury  to 
the  head  might  have  complicated  the  results. 

Among  the  500  cases  were  51,  or  10.2  per  cent,  in  which 
serious  or  fatal  cerebral  injury  occurred  as  a  result  of  the 
anemia.  In  securing  these  figures  the  conditions  for  which 
ligation  was  done  were  disregarded — the  operation  of  ligation 
per  se  being  considered  alone.  It  is  of  interest  to  compare 
this  result  with  the  figures  given  by  Keller  in  the  table  below : 


Author 


Number  of 
Ligations 


Number  of  Cases 

with  Cerebral 

Symptoms 


Number  of  Deaths 


Le  Fort 
Pilz  (i), 
Pilz  (2) , 
Sattler. 
Keller.. 


370 

520 

139 

63 

47 


100  or  ly  .oYo 

165  "32.0% 

32  "23.0% 

4  "    6.3% 

4"    8.5% 


71  or  21 .0% 

91  "  17-5% 
20  "  14.0% 

3  "    4-5% 

4  "    8.5% 


From  this  table  it  is  readily  seen  that  there  is  a  consider- 
able variation  in  the  number  of  cases  in  which  cerebral  symp- 
toms occurred.  The  later  the  cases  occurred  chronologically 
the  better  the  results,  i.  e.,  up  to  a  certain  extent.  This  is 
doubtless  due  to  the  general  improvement  in  surgical  methods, 
particularly  as  regards  asepsis. 

In  analyzing  the  above  51  fatal  cases  it  was  found  that 
they  could  be  classified  as  follows  : 


58  SURGIC-\L  ANEML\  AND  RESUSCITATION 

1.  Number  of  cases  with  hemiplegia  of  the  oppo- 

site side   from   that  on  which   the   ligation 

was  made  (including  4  cases  with  cerebral 

abscess)    42  =  8.4%  (of  500) 

2.  Number  with  hemiplegia  of  the  same  side..     0  =  0.0% 

3.  Number  with  "paralysis"  and  inflammation  of 

dura  mater i  =  0.4% 

4.  Number  without  paralysis  but  with  other  or 

not  clearly  stated  fatal  injuries  of  cerebral 

origin   8  ^  1.6% 

Among  the  42  cases  with  hemiplegia  (see  No.  i  above)  there 
were: 

1.  Fatal   cases,   death   occurring  within   a   com- 

paratively short  time 34  =  6.8%  (of  500) 

2.  Recoveries  with  permanent  paralysis   (so  far 

as  could  be  determined) 6  =  1.2% 

3.  Recoveries  with  stated  transient  paralysis.  . .  .     2  =  0.4% 

Not  included  under  recoveries  with  transient  paralysis  (see 
No.  3  above)  were  certain  cases  in  which  symptoms  occurred 
which  probably  could  be  attributed,  at  least  in  part,  to  cerebral 
anemia;  such  symptoms  as  "peculiar  sensation  in  arm  of 
opposite  side" ;  "weakness  in  opposite  arm" ;  opposite  arm 
and  leg  somewhat  weaker,  with  hair  of  head  turned  from 
black  to  gray  and  the  hair  of  the  opposite  side  from  the  hga- 
tion  thought  to  be  grayer  than  that  of  the  same  side,  and  with 
temporary  pallor  of  the  same  side  of  the  head;  headache,  un- 
pleasant fullness  in  the  head  for  three  years,  when  the  patient 
died;  stupor  for  48  hours;  serous  apoplexy  (in  a  case  of 
pulsating  tumor  of  the  orbit)  ;  convulsions  immediately  after 
tightening  the  ligature;  pallor,  cold  sweat,  and  strabismus — 
all  on  the  side  on  which  the  ligation  was  done. 

In  the  fatal  hemiplegia  cases  which  came  to  autopsy  the 
cerebral  lesion  was  found  invariably  on  the  same  side  as  that 
on  which  the  ligation  was  done,  while  the  opposite  side  of 
the  body  had  been  paralyzed  while  life  lasted.     In  only  one 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  59 

case  in  the  entire  series  was  embolism  reported  to  have  been 
found,  one  of  Siegrist's  cases,  and  in  that  the  middle  cerebral 
artery  was  not  affected.  The  patient  was  a  man,  47  years  of 
age,  who  had  carcinoma  of  the  tongue  and  secondary  hemor- 
rhage. The  right  common  and  internal  carotids  were  tied. 
At  the  moment  when  the  ligature  was  tightened  the  patient  be- 
came pale  and  cyanotic,  the  pulse  and  respiration  ceased,  the 
sensoria  were  lost  immediately  (the  operation  was  done  under 
cocain),  both  pupils  were  dilated,  the  right  almost  completely, 
the  left  to  a  lesser  degree,  but  all  these  symptoms  ceased  after 
about  two  minutes.  Later  in  the  day  he  complained  that  he 
could  not  see  with  his  right  eye,  and  the  typical  signs  of  em- 
bolism of  the  central  artery  of  the  retina  appeared.  This  was 
confirmed  at  the  autopsy.  In  addition  a  thrombus  was  found 
in  the  internal  carotid  artery  which  continued  into  the  middle 
cerebral  artery,  the  artery  of  the  corpus  callosum,  and  the 
posterior  communicating  artery. 

The  mere  fact  that  the  above  case  was  the  only  one  of 
embolism  found  in  the  series  strengthens  the  view  that  cere- 
bral injury  following  ligation  of  the  common  carotid  is  due  to 
ligation  rather  than  to  embolism,  just  as  in  ordinary  cases  of 
apoplexy  the  lesions  are  caused  by  anemia,  and  it  matters  litt-le 
where  the  obstruction  is  as  long  as  the  blood  supply  is  shut  off. 

That  anemia  may  not  always  be  due  to  ligation  directly  is 
suggested  by  the  autopsy  reports  of  certain  cases,  notably  Sie- 
grist's (see  above),  in  which,  as  stated  already,  a  thrombus 
was  found  to  extend  from  the  point  of  ligation  for  quite  a  dis- 
tance into  the  common  carotid,  with  prolongations  into  some 
of  its  branches,  no  embolism  being  detected.  In  a  case  of  fatal 
hemiplegia  reported  by  Zimmerman,  in  which  both  the  com- 
mon and  internal  carotids  were  ligated,  there  was  found  as- 
cending thrombosis  in  the  internal  carotid,  which  extended 
into  the  middle  cerebral,  the  anterior  communicating,  and  the 


6o  SURGICAL  ANEMIA  AND  RESUSCITATION 

artery  of  the  corpus  callosum.  Hemiplegia  had  not  developed 
until  evening  of  the  day  of  the  operation,  death  taking  place 
on  the  third  day.  In  a  second  case  of  Zimmerman's  the  com- 
mon, internal,  and  external  carotids  were  tied.  At  the  autopsy 
ascending  thrombosis  was  found  in  the  internal  carotid  with 
extension  into  the  middle  cerebral  artery,  the  artery  of  the  cor- 
pus callosum,  the  internal  capsule,  the  corona  radiata,  and 
the  temporal  lobe.  Acute  meningitis  and  a  double  inspiration 
pneumonia  were  present,  the  attack  of  hemiplegia  having  come 
on  on  the  day  after  the  operation,  with  death  occurring  on 
the  fourth  day. 

In  regard  to  the  local  conditions  in  the  brain  itself,  it  may 
be  said  that  the  autopsy  reports  stated  almost  invariably  that 
"cerebral  softening"  was  present  on  the  side  on  which 
the  ligation  was  done.  In  one  case  of  hemiplegia  it  was  re- 
ported that  the  consistency  of  the  brain  was  unaltered,  but 
that  there  was  light  stippling  (Punktirung)  of  the  white 
matter.  In  most  of  the  cases  the  softening  seemed  to  be 
throughout  the  hemisphere,  although  in  a  few  cases  it  was 
localized,  e.g.,  in  one  it  was  in  the  temporo-occipital  and  parie- 
tal region,  in  another  in  the  corpus  striatum,  and  in  a  third 
around  the  margins  of  the  fissure  of  Sylvius.  In  a  case  of 
Dubreuil's  the  under  half  of  the  frontal  lobe  showed  extrava- 
sation of  blood  from  two-thirds  of  its  substance  with  one-half 
of  this  area  apparently  softened.  In  one  case  only,  in  which 
other  factors  were  not  present  to  account  for  it,  was  edema 
stated  to  have  been  present. 

In  considering  the  etiology  of  cerebral  injury  after  ligation 
of  the  common  carotid  it  may  be  stated  at  the  outset  that  the 
dangers  accompanying  surgical  interference  with  the  circula- 
tor v  system  of  the  aged  are  in  direct  ratio  to  the  age  of  the 
patient.  In  the  500  cases  studied  the  age  of  the  patient  was 
stated  349  times.    Of  the  349  patients  there  were  301  in  whom 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  6 1 

cerebral  symptoms  were  stated  to  have  been  absent,  or  not 
stated  to  have  been  present.  The  average  age  of  the  301  pa- 
tients w^as  33.6  years.  In  the  48  cases  of  cerebral  injury  in 
which  the  age  was  stated  the  average  age  was  41.5  years. 
Therefore,  in  so  far  as  such  a  rough  comparison  may  have 
weight,  the  older  the  person  the  greater  the  likelihood  of  cere- 
bral injury. 

Conditions  for  which  the  common  carotid  artery  have  been 
ligated  are  varied,  and  some  of  them  are  now  of  historic  in- 
terest only.  The  following  table  shows  the  distribution  in 
the  500  cases : 

1.  Hemorrhag'e    (including-  traumatic   aneurysms)....   206  =  41.2% 

2.  Tumors  (almost  all  malignant) 100  =  20.0% 

3.  Traumatic  pulsating  exophthalmos,  spontaneous  pul- 

sating exophthalmos,   and  aneurysms  of  orbit....  91  =  18.2% 

4.  Spontaneous  aneurysms  other  than  of  the  orbit 76^15.2% 

5.  Trifacial  neuralgia    11=   2.2% 

6.  Preliminary  ligations   for  hemostasis 8=    1.6% 

7.  Epilepsy   3  =    0.6% 

8.  Miscellaneous  and  unclassified 5=    1.0% 


500 


Among  the  tumor  cases  it  was  stated  in  only  one  instance  that 
ligation  was  done  to  starve  the  tumor.  In  fact,  in  most  of 
these  cases  control  of  hemorrhage  was  the  object  sought.  Con- 
sequently a  truer  figure  to  represent  the  hemorrhage  cases 
would  be  61.0  per  cent. 

No  attempt  has  been  made  to  arrive  at  the  conclusions  as 
to  the  bearing  of  the  general  mortality  in  these  cases  on  liga- 
tion. In  the  first  place,  particularly  among  the  traumatic 
cases,  the  injuries  for  which  ligation  was  done  were  so  severe 
that  they  overshadowed  the  possible  effects  of  the  ligation 
itself.     The  high  mortality  attributed  by  certain  authors  to 


62  SURGICAL  ANEMIA  AND  RESUSCITATION 

ligation  should  probably  be  attributed  in  great  part  to  shock, 
hemorrhage,  and  infection.  It  would  be  manifestly  illogical 
to  classify  a  death  in  a  case  of  traumatic  pulsating  exophthal- 
mos, the  result  of  fracture  of  the  base  of -the  skull,  as  due  to 
cerebral  injury  resulting  from  ligation  alone.  The  same 
would  be  true  of  a  death  the  result  of  a  head  wound  from  a 
rifle  ball  or  fragment  of  a  shell.  It  is  equally  illogical  to  pre- 
sent cases  of  pulsating  exophthalmos  as  affording  evidence 
that  the  eyes  may  be  injured  by  ligation  of  the  common  carotid 
artery.  The  usual  cause  of  pulsating  exophthalmos  is  rupture 
of  the  internal  carotid  in  the  cavernous  sinus,  and  in  cases 
which  are  not  treated  at  all  vision  is  frequently  lost  on  the 
affected  side. 

There  is  evidence  of  but  few  cases  of  serious  injury  to  any 
of  the  organs  of  the  special  senses,  due  to  ligation  alone.  The 
pupil  of  the  same  side  may  be  narrowed  temporarily,  although 
not  in  all  cases;  but  in  practically  all,  if  not  in  all  cases,  this 
is  followed  by  permanent  dilatation.  Various  observers  have 
noted  temporary  disturbances  of  the  circulation  of  the  eye, 
such  as  pallor  of  the  papilla,  a  weakened  circulation  in  the 
arterial  branches,  and  a  diminished  fulness  of  the  veins.  After 
ligation  of  both  common  carotids  Jacobi  and  Ehrmann  ob- 
served dimming  of  the  eyesight. 

As  to  cerebral  injury,  it  has  been  found  that  the  time  of 
occurrence  of  cerebral  symptoms  in  relation  to  the  time  of 
ligation  varied  considerably.  Some  authors  claim  that  cere- 
bral symptoms  are  not  manifested  immediately.  In  this  con- 
nection the  case  reported  by  Quenu  is  of  interest  in  spite  of 
the  fact  that  no  autopsy  was  held.  The  age  of  the  patient  is 
not  stated.  He  had  had  an  operation  for  epithelioma  of  the 
neck  with  severe  hemorrhage  from  the  carotid.  Preparations 
were  made  to  ligate  the  common  carotid  without  the  use  of 
a  general  anesthetic.     Just  before  the  ligature  was  tightened 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  63 

the  patient  replied  in  a  normal  way  to  a  remark  made  to  him, 
and,  although  anemic,  had  previously  seemed  to  be  normal 
mentally.  To  quote  Ouenu's  own  words  (translation)  :  *T 
tightened  the  ligature,  and  at  the  instant  the  patient  passed 
into  coma :  the  entire  left  side  was  struck  by  flaccid  paralysis. 
The  patient  died  in  the  evening  or  the  next  morning  without 
having  regained  consciousness."  Whether  or  not  an  autopsy 
was  held  for  confirmation  of  the  cause  of  death  the  whole 
occurrence  was  perfectly  consistent  with  what  well  might- 
happen,  especially  with  a  brain  in  a  previously  anemic  condi- 
tion through  general  loss  of  blood  and  with  the  consequent 
physical  impairment  of  the  brain  cells. 

In  two  other  instances  among  the  cases  studied  paralysis 
was  said  to  have  occurred  immediately  after  the  ligature  was 
tightened.  The  first,  a  case  of  Verneuil's,  was  a  man  30  years 
of  age  who  had  received  a  shot  wound  of  the  cheek.  Hemi- 
plegia and  coma  resulted  immediately  with  death  42  hours 
later.  At  the  autopsy  the  cerebral  hemisphere  on  the  side  of 
the  ligation  was  found  to  be  profoundly  altered.  The  second, 
a  case  of  Hopmann's,  was  a  man,  23  years  of  age,  who  also 
had  received  a  shot  wound  in  the  cheek.  Immediately  after 
ligation  partial  paralysis  of  the  entire  opposite  side  of  the 
body  occurred.  It  was  a  pus  case,  and  eventually  the  eyeball 
had  to  be  enucleated.    The  patient  recovered. 

The  table  on  page  64  shows  the  time  in  which  cerebral 
symptoms  were  manifested  in  51  cases  in  which  they  oc- 
curred. 

Further  studies  showed  also  that  in  general  the  older  the 
patient  the  earlier  the  cerebral  symptoms  occurred. 

In  the  study  of  these  500  cases  it  was  found  that  the  in- 
ternal jugular  vein  of  the  same  side  as  that  on  which  the 
common  carotid  artery  was  ligated  was  occasionally  either 
ligated  also  or  rendered  functionless  through  injury.     This 


64 


SURGICAL  ANEMIA  AND  RESUSCITATION 


Number  of 
Cases 

2 
I 
I 
I 
I 
I 
2 
I 
I 

3 
I 
6 

5 
I 
I 
3 

2 


Total       51 


Time  of  Appearance  of 
Cerebral  Symptoms 

34  days. 

31 
26 
21 

19 
II 
10 

7 
6 
5 
4 
3 
2 

I  day. 
20  hours. 
12 
"immediately  after". 
Indefinitely  stated  or  not 
stated  at  all. 


In  the  33  cases  in  which  the  time  was  stated  it  is  found  that  in  24, 
or  y2.y  per  cent.,  the  symptoms  were  manifested  in  less  than  a  week. 


occurred  in  16  cases,  or  3.2  per  cent.  Among  the  16  cases 
were  4  in  which  cerebral  complications  occurred — hemiplegia 
in  each  case.  Whether  ligation  of  the  internal  jugular  had 
anything  to  do  with  the  causation  of  cerebral  symptoms  is 
impossible  to  state.  Owing  to  the  richness  of  the  venous  anas- 
tomoses of  the  head  it  seems  hardly  probable  that  it  did.  In 
any  case,  if  there  were  not  free  anastomosis  then  stoppage  of 
a  large  venous  trunk  would  tend  to  produce  hyperemia  rather 
than  anemia. 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES 


65 


The  Author's  Cases  of  Temporary  Simultaneous  Closure  of  Both  Common 
Carotid  Arteries  ^ 


Case 
No. 


Sex 

Age 

M. 
F. 

'  'm.'  ' 

46 
21 
48 
58 

7  mos. 

Nature  of  Operation 

Fibrosarcoma  of  mouth 

Congenital  tumor  of  neck 

Epithelioma  of  mouth 

Epithelioma  of  mouth 

Epithelioma  of  lower  jaw 

Angiosarcoma  of  cheek,  and  neck,  of  rapid 

growth 

Carcinoma  of  nasal  septum 

Carcinoma  of  tongue 


Ligation 


Clamps 
Clamps 
Clamps 
Clamps 
Clamps 

Clamps 
Clamps 
Clamps 


Cerebral 
Symptoms 


None 
None 
None 
None 
None 

None 
None 
None 


Result 


Recovery 
Recovery 
Recovery 
Recovery 
Recovery 

Recovery 
Recovery 
Recovery 


1  From  "  Problems  Relating  to  Surgical  Operations,"  Crile. 


TECHNIQUE  OF  LIGATION  OF  THE  COMMON  CAROTID 
ARTERY  AND   ITS   BRANCHES 

Formerly  ligation  of  the  common  carotid  artery  was  some- 
times done  when  the  comparatively  modern  procedure  of  tem- 
porarily closing  the  vessel  would  have  better  served  the  inter- 
ests of  the  patient.  The  author  has  repeatedly  demonstrated 
that,  when  properly  done,  an  artery  may  be  closed  temporarily 
without  injury  for  as  long  a  time  as  is  ever  required  for  an 
operation.  Consequently  certain  operations  on  the  head,  for 
example,  in  which  hemorrhage  is  troublesome,  can  be  done 
with  much  greater  ease  and  safety  by  temporary  closure  of 
the  common  carotid.  By  this  procedure  the  local  field  is  in 
better  condition  for  the  careful  dissection  which  is  so  often 
necessary,  and  the  danger  of  harmful  cerebral  anemia  is  al- 
most completely  avoided.  Moreover,  as  a  preliminary  step  to 
permanent  ligation  temporary  closure  should  be  done  when 
possible.  This  point  the  author  wishes  to  emphasize  strongly. 
There  are  very  few  cases  in  which  it  cannot  be  done,  and  the 
occurrence  of  harmful  immediate  symptoms  can  be  taken  as  a 
warning  against  making  a  permanent  ligation. 

The  following  observations  constitute  a  brief  resume  of 
the  author's  experimental  work  to  determine  the  effect  of  a 


66  SURGICAL  AXEML\  AXD  RESUSCITATIOX 

temporary  closure  of  the  carotid :  The  immediate  effect  on 
the  circulation  of  the  temporary  closing  of  one  carotid  artery 
was  to  increase  the  blood  pressure,  but  usually  a  compensation 
followed,  and  the  pressure  returned  to  its  normal  level.  Xo 
effect  upon  the  respiration  was  observed.  The  simultaneous 
closure  of  both  carotid  arteries  produced  a  greater  rise  in  the 
blood-pressure,  which  also  by  physiologic  compensation 
usually  soon  returned  to  the  normal  level.  In  many  of  the 
latter  experiments  there  was  a  decrease  in  the  respiratory 
action,  although  the  eft'ect  was  very  slight.  In  no  instances 
were  any  striking  results  noted.  In  the  recovery  experiments 
no  effect  upon  the  animal  was  observed  beyond  that  attribut- 
able to  the  anesthesia  and  the  operation  in  the  cases  in  which 
the  clamps  were  alloAved  to  remain  on  the  arteries.  The  ani- 
mals seemed  playful  and  strong.  Even  after  24  hours  of  com- 
plete closure  there  was  but  little  microscopic  evidence  of  in- 
jury to  the  vessel  wall.  Circulation  through  the  clamped  por- 
tion was  readily  reestablished.  However,  in  cases  in  which 
the  animal  had  suft'ered  infective  inflammation  of  the  wound 
during  the  application  of  clamps  for  a  considerable  length  of 
time,  say  for  two  days,  the  damage  to  the  vessel  walls  was 
marked,  and  in  some  cases  the  lumen  was  occluded.  As  to  the 
after-effects,  in  no  case  was  there  any  clotting;  the  aseptic 
cases  made  good  recoveries;  the  circulation  was  reestablished; 
and  no  impairment  of  consequence  occurred.  The  cerebral 
vessels  were  carefully  observed  at  autopsy,  and  in  no  case 
were  either  emboli  or  thrombi  found,  nor  was  there  noted  any 
gross  eft'ect  on  the  brain. 

In  the  course  of  clinical  operations  the  author  has  tem- 
porarily closed  the  common  carotid  artery  136  times.  The 
ages  of  the  patients  ranged  from  7  months  to  69  years.  In 
every  instance  the  circulation  was  resumed  as  soon  as  the 
clamps  were  removed.     There  were  no  appreciable  late  effects 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  67 

on  the  vessel  wall  at  the  point  of  clamping,  and  none  on  the 
circulation  in  the  closed  arteries  and  their  branches.  Less 
anesthetic  was  necessary  in  those  cases  in  which  both  common 
carotids  were  closed.  The  respiration  might  be  embarrassed, 
but  was  relieved  by  partially  releasing  the  pressure  on  one  cr 
both  vessels.  The  operation  time  was  much  diminished  as  a 
result  of  the  freedom  from  blood  of  the  field  of  operation, 
and  the  amount  of  blood  lost  was  much  lessened,  as  was  the 
difficulty  of  keeping  blood  out  of  the  respiratory  tract. 

In  the  closure  of  the  common  carotid  artery,  a  valuable 
clinical  procedure  is  to  transfer  the  clamp  to  the  external  caro- 
tid just  as  soon  as  the  latter  vessel  is  reached,  as,  for  example, 
in  a  block  dissection  of  the  neck.  In  elderly  subjects,  espe- 
cially those  with  atheromatous  arteries,  distinct  cerebral  im- 
pairment, amounting  even  to  mild  delirium,  may  appear  after 
temporary  closure  of  the  common  carotid  artery  and  last  for 
several  days,  but  apparently  no  permanent  damage  is  done  to 
the  brain.  Since  the  adoption  of  this  method  of  closing  the 
external  carotid  artery  from  the  beginning  of  the  operation, 
or  transferring  the  clamp  in  the  course  of  the  operation,  no 
functional  impairment  of  the  brain  has  been  observed. 

In  the  author's  experience  closure  of  the  common  carotid 
artery  does  not  arrest  hemorrhage  as  completely  as  does 
closure  of  the  external  carotid.  The  reason  is  that  when  the 
common  carotid  is  closed  and  the  external  is  open  there  is  a 
back  flow  of  blood  via  the  anastomoses  in  the  circle  of  Willis. 
This  explains  why  rather  free  hemorrhage  may  be  seen  when 
the  common  alone  is  closed.  The  best  control  of  all  is  secured 
by  closing  both  external  carotids. 

In  his  own  series  of  cases  the  author  has  observed  no  in- 
stances of  embolism  or  thrombosis  as  a  secondary  result  of  the 
temporary  closure  of  either  common  or  external  carotids. 

As  a  general  principle  it  stands  to  reason  that,  other  fac- 


68  SURGICAL  ANEMIA  AND  RESUSCITATION 

tors  not  interfering,  the  ligation  of  a  large  artery  should  not 
be  done  when  a  small  branch  of  the  same  vessel  can  be  reached, 
the  closure  of  which  will  control  the  bleeding.  In  regard  to 
the  carotids  no  one  has  emphasized  this  more  strongly  than 
Wyeth.  In  his  classical  "Essays  in  Surgical  Anatomy,"  pub- 
lished in  1878,  he  says:  "I  cannot  conclude  the  surgical 
anatomy  of  these  arteries  without  protesting  with  all  the  earn- 
estness I  may  possess  against  the  operation  of  tying  the  com- 
mon carotid  for  lesions  of  the  external  carotid  or  its  branches 
when  this  last  vessel  may  be  ligated." 

While  a  discussion  of  the  surgical  anatomy  of  the  vascular 
system  of  the  head  and  neck  is  rather  outside  of  the  province 
of  this  book  it  has  a  direct  enough  bearing  to  make  the  fol- 
lowing extracts  from  Wyeth  pertinent : 

"i.  In  all  intracranial  lesions  involving  alone  the  inter- 
nal carotid  or  its  branches  this  vessel  should  be  tied.  If  this 
procedure  is  not  successful  then  the  external  carotid  should 
be  secured  at  the  crossing  of  the  digastric.  If  the  facial  be 
given  off  below  this  point  it  should  be  secured  by  a  separate 
ligature.  .  .  .  For  lesions  of  the  internal  carotid  in  the  neck 
(excepting  aneurysm)  it  should  be  tied  above  and  below  the 
lesion  in  all  cases.  The  operation  on  the  cardiac  side  alone, 
be  the  common  or  internal  trunk  the  seat  of  the  ligature,  is 
not  justifiable,  death  having  occurred  in  many  instances 
through  the  descending  current  from  the  circle  of  Willis. 
In  aneurysm  of  this  artery  the  single  ligature  on  the  cardiac 
side  will  suffice. 

"2.  When  the  lesion  (excepting  aneurysm)  exists  within 
one-half  inch  of  the  bifurcation  of  the  common  carotid,  in- 
volving this  vessel,  or  the  external  or  internal,  or  both,  the 
common  trunk  must  be  tied  on  the  cardiac  side,  and  the  other 
two  arteries  on  the  distal  side  of  the  lesion.  The  superior 
thyroid  and  any  other  branches  of  the  external  carotid  be- 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  69 

tween  the  ligature  upon  this  vessel  and  the  bifurcation  should 
also  be  secured. 

"In  case  of  aneurysm  in  either  of  these  points  the  single 
ligature  on  the  cardiac  side  will  usually  suffice. 

"3.  In  erectile  or  pulsating  tumors  of  the  orbit  (intra- 
orbital aneurysm)  ligature  of  the  common  carotid  is  to  be 
advised.  .  .  .  Since  the  anastomoses  between  the  termi- 
nal branches  of  the  external  and  internal  carotids,  through 
the  orbit,  are  more  or  less  exaggerated  in  intraorbital  aneur- 
ysm ...  I  am  of  the  opinion  that  the  ligature  of  the 
common  carotid  is  the   surest  and  safest  operation     . 

"4.  Wounds  of  the  superior  thyroid  artery  too  near  its 
origin  to  permit  a  ligature  on  the  cardiac  side  of  the  lesion 
require  deligation  of  the  common,  external,  and  internal  caro- 
tids and  torsion  of  the  distal  end  of  the  wounded  vessel. 

"5.  In  incised,  punctured,  lacerated,  and  gunshot  wounds 
of  the  external  carotid  or  its  branches  where  it  is  deemed  in- 
expedient to  secure  the  vessel  at  the  seat  of  injury  the  external 
carotid  of  one  or  both  sides  should  be  secured  below  the  origin 
of  the  lingual  ...  If  the  lingual  or  any  other  branch  is 
in  immediate  contact  with  the  ligature  it  (or  they)  should  be 
also  secured, 

"The  common  trunk  should  never  be  tied  under  such  cir- 
cumstances except  as  a  last  resort. 

"6.  Hemorrhage  of  the  tonsils  and  pharynx,  if  not  ar- 
rested by  ligature  of  the  external  carotids  as  advised,  will 
require  either  the  separate  ligature  of  the  pharyngeal  ascendens 
or  of  the  common  and  internal  carotids. 

"7.  It  must  be  assumed  that  when  the  ligature  of  the 
external  carotid  below  the  origin  of  the  lingual  does  not 
arrest  hemorrhage  from  the  pharynx  the  bleeding  is  from  the 
ascending  pharyngeal,  and  that  this  branch  originates  from 
the  bifurcation  of  the  internal  carotid.     .     .     .      (The  history 


70  SURGICAL  ANEMIA  AND  RESUSCITATION 

gives  one  or  two  deaths  from  hemorrhage  from  the  tonsils 
after  hgature  of  the  common  trunk  alone.) 

"8.  Aneurysm  of  the  external  carotid  or  its  branches 
(excepting  the  superior  thyroid)  demands  deligation  of  the 
external  carotid  alone  when  a  sufficient  space  exists  between 
the  tumor  and  the  bifurcation  to  admit  the  hgature  with 
safety. 

"9.  Aneurysm  of  the  internal  carotid  should  be  treated 
by  ligature  of  this  vessel  alone  when  there  is  sound  artery 
enough  between  the  tumor  and  the  bifurcation  to  admit  the 
ligature  with  safety. 

"10.  Aneurysm  of  the  common  carotid  (if  digital  com- 
pression shall  have  been  abandoned)  should  be  treated  by 
ligature  of  this  vessel  as  far  from  the  tumor  (on  cardiac 
side)  as  possible. 

"11.  Ligature  of  the  common  carotid  for  aneurysm  of  the 
arch  of  the  aorta  is  of  doubtful  propriety. 

"12.  Ligature  of  the  common  carotid  alone  for  the  cure 
of  innominate  aneurysm  is  an  exceedingly  dangerous  pro- 
cedure; 12  of  17  cases  proved  fatal  from  the  operation; 
only  2  were  cured.     .     . 

"16.  In  epilepsy,  while  the  danger  of  death  as  a  result  of 
the  operation  is  comparatively  slight  (5  per  cent.),  the  pro- 
portion of  cures  or  improved  cases  is  not  great  enough  to 
commend  this  procedure  to  the  profession.     .     . 

"17.  In  persistent  and  exhaustive  neuralgia  of  the  fifth 
nerve  when  all  other  methods  have  proved  ineffectual  liga- 
tion of  the  common  carotid  should  be  practiced. 

"The  external  carotid  of  one  or  both  sides  should  first 
be  tied  below  the  lingual  (the  point  of  election).  If  this 
fails  the  common  trunk  upon  the  affected  side  may  be  secured. 

"The  operation  is  contraindicated  when  pressure  upon  the 
common  carotid  of  the  affected  side  does  not  arrest  the  pain. 


LIGATION  OF  THE  COMMON  CAROTID  ARTERIES  71 

"18.  In  hemiplegia  or  headache  the  ligature  of  the  com- 
mon carotid  is  not  justifiable.     ,     .     ." 

Facts  like  the  foregoing  furnish  an  invaluable  basis  for 
the  control  of  hemorrhage — one  of  the  most  important  parts 
of  the  surgery  of  the  head  and  neck.  Their  value  in  pre- 
venting surgical  anemia  as  far  as  possible  lies  in  the  light  they 
throw  on  how  best  to  avoid  unnecessary  closure  of  arterial 
trunks — a  secondary  but  important  matter. 

In  addition  to  what  has  already  been  presented  a  few 
words  may  well  be  said  in  regard  to  ligation  of  the  external 
carotid.  While  the  weight  of  evidence  is  overwhelmingly 
against  the  probability  that  ligation  of  the  external  carotid 
may  cause  harmful  or,  in  fact,  any  cerebral  anemia  that  can  be 
manifested  clmically,  nevertheless  it  may  not  always  be  a 
harmless  surgical  procedure,  as  is  shown  by  the  following  case 
of  Scudder. 

The  patient  was  a  woman,  50  years  of  age,  with  sarcoma 
of  the  superior  maxilla.  The  left  external  carotid  artery  was 
ligated  just  below  the  origin  of  the  facial  artery,  the  patient 
being  in  the  sitting  posture.  Then  the  jaw  was  completely 
excised.  On  the  next  day  a  right  hemiplegia  developed. 
Death  occurred  six  days  later,  the  patient  being  partially  un- 
conscious during  that  time.  The  left  middle  cerebral  artery 
was  found  at  the  autopsy  to  be  occluded  a  short  distance  from 
its  point  of  origin  by  a  firm,  gray-red,  thrombus-like  mass, 
which  was  apparently  prolonged  into  some  of  the  branches  of 
the  artery  as  a  blackish  red,  somewhat  softer  material.  At 
the  site  of  the  basal  ganglia  on  the  left  side  there  was  a 
pale,  in  places  grayish-red,  disorganized,  more  or  less  dis- 
integrated soft  mass  of  brain  tissue,  which  extended  from  the 
posterior  portion  of  the  left  frontal  lobe  back  as  far  as  the 
posterior  portion  of  the  thalamus  laterally,  to  the  left  of  and 
involving  a  good  part  of   the  striate  body  and   downward 


72  SURGICAL  ANEMIA  AND  RESUSCITATION 

into  the  temporal  lobe.  In  the  left  temporal  lobe  the  con- 
dition extended  over  quite  an  area,  and  reached  as  far  as 
the  cortical  portion.  In  this  situation  the  brain  tissue  was 
pale,  disintegrated,  and  mushy.  Elsewhere  the  brain  tissue 
was  not  remarkable.  There  was  no  evidence  of  arteriosclerosis 
of  the  circle  of  Willis, 

SUMMARY 

The  histologic  evidence  that^  even  in  so-called  "recovered" 
animals,  some  or  even  many  nerve  cells  are  permanently  lost 
and  that  all  are  temporarily  damaged  explains  the  great  tem- 
porary and  lesser  permanent  loss  of  power  following  any 
grave  anemia  of  the  brain. 

It  argues  against  the  practice  of  permitting  the  blood 
pressure  to  fall  extremely  low  in  cases  of  hemorrhage  before 
resorting  to  transfusion.  It  warns  the  surgeon  to  be  cautious 
in  ligating  or  temporarily  closing  the  common  carotid  artery 
in  aged  subjects.  It  warns  him  not  to  press  on  the  brain  with 
retractors  and  packings  unless  the  pressure  is  made  strictly 
intermittent,  never  exceeding  five  minutes  at  a  stretch.  It 
explains  the  reason  why  in  all  types  of  brain  pressure  the 
early  depression  of  the  higher  functions,  such  as  associative 
memory,  occurs  before  the  depression  of  the  lower  functions, 
such  as  respiration  and  circulation.  It  emphasizes  the  signifi- 
cance of  the  gradual  onset  of  dulness  and  stupor  in  increased 
intracranial  pressure.  It  fixes  an  absolute  limit  to  the  possi- 
bility of  resuscitation  in  cases  of  drowning,  and  therefore 
makes  one  doubt  the  authenticity  of  many  reported  cases  of 
resuscitation  after  apparently  long  intervals  of  suspended  ani- 
mation. 


CHAPTER  III 

ANEMIA    OF    VOLUNTARY    MUSCLES  I     EXPERIMENTAL    OBSERVA- 
TIONS.     ANEMIA   OF   THE    POSTERIOR    EXTREMITY   OF   DOGS 

In  collaboration  zvith  Dr.  Lawrence  Pomeroy  and 
Dr.  A.  M.  Tweedie 

How  long  can  an  extremity  endure  total  anemia  and  sur- 
vive without  consequent  loss  of  function?  Even  in  dogs  this 
has  not  been  an  easy  matter  to  determine,  on  account  of  the 
variety  of  factors  which  enter  into  the  problem.  One  thing  is 
very  evident  and  that  is,  that  while  a  dog's  thigh  may  have  a 
tourniquet  applied  to  it  so  as  to  shut  off  all  circulation  for 
even  as  long  a  time  as  ten  hours,  and  so  that  twenty-four 
hours  later  there  is  complete  loss  of  function  with  disturbance 
in  the  electrical  reactions  (except  the  reaction  of  degenera- 
tion), yet  no  microscopical  changes  of  a  structural  nature 
can  be  detected  at  this  time.  The  same  dog  if  allowed  to 
live  will  show  paralysis  of  a  permanent  nature,  with  or  with- 
out the  subsequent  development  of  the  reaction  of  degenera- 
tion, and  hence  the  irreparable  damage  is  done  at  the  end  of 
the  twenty-four  hours  even  if  nothing  but  edema  and  inter- 
stitial hemorrhages  be  present.  What  will  eventually  become 
irreparable  loss  of  function  is  not  indicated  by  early  struc- 
tural changes. 

In  a  rough  way  it  may  be  said  that  permanent  paralysis 
usually  follows  anemia  of  a  dog's  thigh  of  seven  hours'  dura- 

73 


74  SURGICAL  ANEMIA  AND  RESUSCITATION 

tion.  Recovery  to  the  extent  of  apparently  complete  restora- 
tion of  function  has  occurred  after  a  longer  time,  but  in  a 
useful  leg  even  grave  microscopic  changes  may  be  found  when 
the  animal  is  killed,  so  that  to  a  certain  extent  appearances 
may  be  very  misleading. 

In  regard  to  loss  of  knee-jerk  the  findings  are  quite  con- 
stant. The  knee-jerk  was  always  lost  after  the  6-hour  or 
longer  durations  of  anemia.  The  fact  that  it  was  always  lost 
after  6  hours  of  anemia  did  not  mean  necessarily  that  it  rnight 
not  return  and  become  entirely  normal  again.  The  shortest 
period  of  anemia  after  which  it  was  lost  was  3  hours,  and  in 
this  particular  case  (Exp.  7)  it  returned  after  12  days. 

The  same  may  be  said  in  regard  to  the  foot-drop — in  fact, 
the  time  of  appearance  of  the  foot-drop  was  almost  identical 
with  the  disappearance  of  the  knee-jerk.  The  muscles  con- 
trolling the  foot-drop  were  always  the  first  to  become  affected 
and  the  last  to  become  normal. 

The  occurrence  of  sensory  paralysis  was  the  most  variable 
of  the  factors  accompanying  muscular  anemia.  It  was  less 
apt  to  be  complete  than  was  the  motor  paralysis,  and  usually 
disappeared  within  the  first  few  days  after  the  experiment. 

The  reaction  of  degeneration  was  variable.  It  was  ob- 
served earliest  in  Experiment  26,  a  7-hour  experiment,  but  in 
two  other  7-hour  experiments  it  was  absent.  In  the  experi- 
ments of  still  longer  duration  it  was  not  invariably  present. 
Possibly  this  was  due  to  the  variation  of  pressure  with  which 
the  tourniquet  was  applied.  For  example,  one  might  use  much 
more  than  sufficient  pressure  to  shut  off  the  circulation,  as  no 
pressure  gauge  was  connected  with  the  tourniquet  employed 
in  the  experiments. 

The  microscopic  changes  showed  rather  definite  progres- 
sion of  degeneration. 

In  all  of  the  following  experiments,  unless  otherwise  spe- 


ANEMIA  OF  VOLUNTARY  MUSCLES  75 

cifically  noted  in  detail,  anemia  of  an  extremity  was  obtained 
by  the  application  of  an  Esmarch  bandage  which  was  tight- 
ened until  arterial  pulsation  ceased,  the  dog  being  under  mor- 
phia and  light  ether  anesthesia  throughout  the  time  of  appli- 
cation. 

Protocols  of  Forty-three  Selected  Experiments 

EXPERIMENT    i 

November  10,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  Tourni- 
quet applied  to  upper  third  of  left  thigh  for  /  hour.  After  the  appli- 
cation no  pulsation  could  be  detected  in  the  femoral  artery.  At  the 
close  of  the  experiment  the  dog  was  in  good  condition. 

November  12. 

The  dog  limped  a  little,  but  the  muscular   strength  of  the  leg 
seemed  to  be  normal.    The  knee-jerk  was  normal. 
November  18. 

Leg  apparently  normal. 
December  i. 

Leg  apparently  normal.  All  reflexes  normal.  Reaction  to  gal- 
vanic and  faradic  currents  normal. 

EXPERIMENT    2 

November  15,  1908. 

Small   mongrel  dog;   condition,   good.     Ether;  morphia,   gr.   ^. 
Tourniquet  applied  to  upper  third  of  left  thigh  for  2  hours.    At  the 
close  of  the  experiment  the  condition  of  the  dog  was  good. 
November  16. 

Some  impairment  of  motion  of  the  affected  leg  was  present,  and, 
while   the   reflexes   were   normal,   the   muscular   power   was   slightly 
diminished.    Reaction  to  galvanic  and  faradic  currents  normal. 
November  17. 

There  was  marked  improvement. 
November  19. 

The  leg  seemed  to  be  normal  in  every  way.  Reflexes  and  electri- 
cal reactions  normal. 

EXPERIMENT    3 

November  23,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  Tourni- 
quet applied  to  upper  third  of  left  thigh  for  2]/^  hours.  At  the  end 
of  the  experiment  the  dog  was  in  good  condition. 


76  SURGICAL  ANEMIA  AND  RESUSCITATION 

November  24. 

There  was  "some  impairment  of  the  muscular  power  and  activity. 
The  knee-jerk  was  present,  and  sensation  seemed  to  be  normal. 

November  25. 

The  leg  was  normal  in  every  way. 

EXPERIMENT    4 

November  24,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  Yz.  Tourni- 
quet applied  to  upper  third  of  left  thigh  for  2Y2.  hours.  At  the  close 
of  the  experiment  the  condition  of  the  dog  was  good. 

November  25. 

The  dog  limped  somewhat,  but  the  leg  was  not  paralyzed.  The 
reflexes  were  normal.  The  dog  was  observed  for  several  days  more, 
but  no  changes  could  be  made  out,  the  anemia  apparently  not  being 
sufficient  to  damage  the  muscle  fibers. 

EXPERIMENT    5 
December  i,  1908. 

Mongrel  dog ;  condition,  good.  Ether ;  morphia,  q.  s.  Tourniquet 
applied  to  right  thigh  for  ^^  hours.  At  the  end  of  the  experiment 
the  condition  of  the  dog  was  good. 

December  2. 

There  was  marked  impairment  of  function  in  the  leg,  but  not 
complete  paralysis.  The  flexor  muscles  of  the  foot  were  more  affected 
than  other  groups.    There  was  occasional  foot-drop. 

December  3. 

The  impairment  had  disappeared,  and  the  muscular  power  seemed 
to  be  normal. 

EXPERIMENT    6 

November  25,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^<.  Tourni- 
quet applied  to  upper  third  of  left  thigh  for  2^  hours.  At  the  close 
of  the  experiment  the  dog  was  in  good  condition. 

November  26. 

There  was  slight  paralysis  of  the  flexors  of  the  foot.  The  other 
muscles  seemed  to  be  normal. 

December  6. 

The  leg  seemed  to  be  normal  to  electrical  stimulation.  The  re- 
flexes were  normal.     The  dog  was  killed,  and  sections  taken. 


ANEMIA  OF  VOLUNTARY  MUSCLES  77 

Microscopical  Examination. — As  a  whole  the  muscle  cells 
showed  reduced  stainability.  The  cross-striations  of  the  cells  were 
much  reduced,  and  entirely  absent  at  the  periphery  of  the  bundles. 
Throughout  the  sections  there  was  marked  fragmentation.  Certain 
areas  showed  regeneration  actively  going  on,  while  in  others  there 
were  marked  hyaline  changes.  The  walls  of  the  blood  vessels  were 
thickened.  There  was  no  hemorrhage  into  the  tissues.  There  was  but 
a  small  degree  of  inflammatory  infiltration. 

EXPERIMENT    7 

November  18,  1908. 

Black  and  tan  bitch ;  condition,  good.  Ether ;  morphia,  q.  s.  A 
tourniquet  was  applied  to  the  upper  third  of  the  left  thigh  for  j  hours. 
At  the  close  of  the  experiment  the  bitch  was  in  good  condition. 

November  19. 

There  was  partial  paralysis  of  all  the  muscles  below  the  tourni- 
quet, and  the  flexors  of  the  foot  were  completely  paralyzed,  with  con- 
sequent complete  foot-drop.  The  reflexes  were  absent.  Sensation  to 
pain  seemed  to  be  delayed,  but  the  electrical  reactions  were  normal. 

November  25. 

The  condition  of  the  leg  was  about  the  same. 

December  i. 

There  was  slight  improvement.     At  times  the  bitch  flexed  her 
foot,  and  there  was  more  motion  in  the  other  partly  paralyzed  muscles. 
The  reflexes  could  not  be  elicited.     Sensation  to  pain  was  more  acute, 
and  the  electrical  reactions  were  still  normal. 
December  15. 

Slow  improvement  had  continued,  with  partial  return  of  muscu- 
lar power.     The  electrical  reactions  continued  to  be  normal. 

December  30. 

The  leg  seemed  to  be  normal  in  every  way,  including  the  reflexes. 

January  7,  1909. 

The  bitch  was  killed  with  chloroform,  and  pieces  of  muscle  taken 
lor  sectioning. 

Microscopical  Examination. — On  the  whole  the  sections  pre- 
sented a  normal  appearance.  In  certain  areas  the  cross-striations 
were  a  little  less  distinct  than  normal,  but  this  may  have  been  due  to 
the  way  the  sections  were  cut.  The  nuclei  stained  perfectly  every- 
where, and  showed  no  signs  of  degeneration,  and  there  was  no  round 
cell  infiltration.    The  sarcolemma  was  slightly  thicker  than  normal. 


78  SURGICAL  ANEMIA  AND  RESUSCITATION 

EXPERIMENT    8 

November  27,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^.  A  tourni- 
quet was  applied  to  the  right  thigh  at  the  junction  of  the  upper  and 
middle  thirds  for  5  hours.  At  the  close  of  the  experiment  the  dog 
was   in   good   condition. 

November  28. 

There  was  but  slight  impairment  of  the  function  of  the  muscles 
below  the  tourniquet.     The  reflexes  were  normal. 

December  i. 

The  return  to  normal  seemed  to  be  complete  in  every  way.     - 

EXPERIMENT    9 

November  30,  1908. 

Bulldog  bitch ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  5  hours.  At 
the  close  of  the  operation  the  dog  was  in  good  condition. 

December  i. 

There  was  almost  complete  paralysis  of  the  muscles  of  the  leg 
below  the  tourniquet  with  foot-drop.     The  knee-jerk  was  not  lost. 

December  2. 

The  condition  was  markedly  better. 

December  28. 

The  leg  was  in  apparently  normal  condition. 

EXPERIMENT    10 
October  9,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5/2.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  thigh  for  j  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition. 

October  10. 

There  was  a  pronounced  toe-drop,  but  the  other  muscles  were  not 
paralyzed,  and  the  electrical  reactions  were  normal.  The  leg  was 
very  sensitive  to  pain,  and  the  dog  howled  whenever  the  leg  was 
touched.     The  temperature  and  pulse  rate  were  normal. 

October  14. 

As  far  as  could  be  determined  the  muscles  were  in  normal  condi- 
tion, except  that,  after  exertion,  the  dog  still  showed  a  slight  toe-drop 


ANEMIA  OF  VOLUNTARY  MUSCLES  79 

on  the  affected  side.    The  electrical  reactions  were  normal,  and  there 
was  no  difference  in  the  reactions  to  pain  between  the  two  legs. 

October  19. 

The  muscles  seemed  to  be  normal  in  every  way. 

November  12. 

The  dog  was  anesthetized,  and  the  adductor  magnus  muscle  re- 
moved and  a  portion  of  the  sciatic  nerve.  No  gross  changes  were  ap- 
parent in  either.    The  histologic  examinations  also  showed  no  changes. 

EXPERIMENT    11 

November  19,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  thigh  for  4  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition. 

November  20. 

The  affected  leg  showed  complete  foot-drop,  and  the  peroneal 
muscles  were  completely  paralyzed.  The  other  muscles  still  retained 
some  power,  but  it  was  much  below  normal.  The  dog  used  the  leg, 
but  walked  on  the  dorsum  of  the  foot  instead  of  the  plantar  surface. 
The  knee-jerk  was  absent.  To  the  faradic  current  there  was  delayed 
reaction,  but  to  the  galvanic  the  reaction  was  normal. 

November  30. 

The  condition  of  the  leg  was  the  same. 

December  i. 

There  seemed  to  be  slight  improvement,  and  the  flexors  of  the 
foot  showed  signs  of  regaining  their  power.  The  reflexes  could  not 
be  obtained. 

December  5. 

The  improvement  was  marked.  The  foot  dropped  occasionally. 
The  knee-jerk  had  returned.  No  change  could  be  made  out  in  the 
electrical  reactions. 

January  4,  1909. 

There  was  no  paralysis  of  the  flexor  muscles.  The  dog  was  killed, 
and  pieces  of  tissue  removed  for  examination. 

Microscopical  Examination. — In  the  muscle  cells  there  was  a 
general  change  involving  all  of  the  cytoplasm.  The  cross-striations 
were  less  plain,  and,  to  a  slight  degree,  fragmentation  had  taken  place. 
Except  for  a  slight  increase  of  the  granules  about  the  nucleolus  the 
nuclei  were  apparently  normal.     There  was  no  inflammatory  infiltra- 


8o  SURGICAL  ANEMIA  AND  RESUSCITATION 

tion.  The  blood  vessels  showed  no  changes.  Throughout  the  sections 
there  was  a  general  increase  of  connective  tissue.  In  certain  areas 
there  was  cloudy  swelling,  which  seemed  to  be  the  result  of  a  previ- 
ous edema.  When  compared  with  fields  of  normal  muscle  it  was 
found  that  there  was  an  increase  in  the  number  of  nuclei,  showing 
that  cell  division  had  been  progressing  faster  than  normal.  The 
sarcolemma  was  not  thickened.  No  nerve  endings  were  made  out  in 
the  preparations. 

EXPERIMENT    12 

October  10,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  4  hours.  At 
the  close  of  the  experiment  the  dog  was  in  good  condition,  no  change 
in  the  respiratory  rate  having  been  noticed. 

October  ii. 

Marked  toe-drop  was  present,  and  the  leg  seemed  to  be  numb. 
The  reflexes  were  absent,  but  the  electrical  reactions  were  normal. 
The  leg  was  dragged,  and  voluntary  movement  was  apparently  lost 
below  the  tourniquet. 

October  16. 

The   symptoms  of  disturbance   had  practically  all   disappeared. 
The  toe-drop  was  shown  only  when  the  dog  was  fatigued,  and  then 
but  slightly.     The  electrical  reactions  were  normal. 

November  12. 

The  dog  was  anesthetized,  and  the  adductor  magnus  muscle  and 
part  of  the  sciatic  nerve  removed.  No  gross  or  miscroscopic  changes 
could  be  detected. 


EXPERIMENT    13 
December  31,  1908. 

Mongrel  dog ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  5  hours. 

January  i,  1909. 

Marked  impairment  of  muscular  power  was  present,  but  not  com- 
plete paralysis.  There  was  marked  paralysis  of  the  flexors  of  the  foot, 
with  resulting  foot-drop. 

January  8. 

The  paralysis  was  somewhat  less.  The  foot-drop  was  still  pres- 
ent, and  the  knee-jerk  was  diminished. 


ANEMIA  OF  VOLUNTARY  MUSCLES  8 1 

January  14. 

Death  occurred  during  the  night  from  unknown  cause,  the  autopsy- 
revealing  no  change  to  which  death  could  be  attributed.  Blocks  of 
tissue  were  taken  for  examination. 

Microscopical  Examination. — The  sections  showed  considerable 
change.  Under  low  power  magnification  infiltration  of  leukocytes 
between  the  muscle  fibers  could  be  seen.  The  fibers  themselves 
were  poorly  stained,  and  the  striae  were  almost  obliterated.  In  many 
areas  the  fibrillse  did  not  show  at  all,  the  entire  fibers  showing  hyaline 
changes.  There  was  a  great  difference  in  the  size  of  the  fibers,  many 
showing  an  increase  in  the  number  of  muscle  nuclei.  These  nuclei 
were  round  or  oval  in  shape,  and  about  three  times  as  large  as  nor- 
mal nuclei.  Marked  fragmentation  had  occurred  in  all  parts  of  the 
sections.     The  sarcolemma  was  greatly  thickened. 

EXPERIMENT    14 

January  4,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  Y^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  5  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition. 

January  5. 

There  was  partial  paralysis  of  the  muscles  below  the  point  of  con- 
striction, and  partial  toe-drop. 

January  8. 

The  condition  was  about  the  same. 

January  12. 

Muscular  power  was  more  nearly  normal.  The  foot  dropped  less. 
The  electrical  reactions  were  negative. 

January  17. 

Marked  improvement  had  occurred,  but  there  was  still  some  im- 
pairment of  the  muscular  power  of  the  foot. 

January  18. 

The  dog  was  killed  in  the  course  of  a  resuscitation  experiment. 
Blocks  of  tissue  were  removed  for  examination. 

Microscopical  Examination. — Extensive  degeneration  had  oc- 
curred. In  some  areas  the  muscle  fibers  could  not  be  distinguished  as 
such  at  all,  on  account  of  proliferation  of  the  nuclei  and  infiltration  of 
leukocytes.  In  an  occasional  area  cross-striation  could  be  seen  imme- 
diately adjoining  fibers  completely  destroyed  and  undergoing  absorp- 


82  SURGICAL  ANEMIA  AND  RESUSCITATION 

tion.     Fragmentation   was   marked,   and   the   sarcolemma   was   thick- 
ened. 

EXPERIMENT    15 

January  23,  1909. 

Mongrel  dog;  condition,  good.     Ether;  morphia,  gr.  y^.    A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  5  hours. 

January  24. 

The  dog  died  during  the  night.     The  microscopical  examination 
showed  only  normal  muscle. 


EXPERIMENT    16 
October  14,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  5  hours. 
At  the  close  of  the  experiment  the  condition  of  the  dog  was  good. 

October  15. 

There  was  complete  paralysis  of  all  the  muscles  below  the  point 
of  constriction.  Foot-drop  was  pronounced.  On  stimulating  with 
the  faradic  current  the  muscles  seemed  to  be  more  irritable  than 
normal.  The  latent  period  was  increased,  but  it  required  less  stimulus 
to  produce  a  maximal  contraction  than  in  the  other  leg.  The  period 
of  contraction  seemed  to  be  shortened,  but,  as  compared  with  that 
of  the  other  leg,  the  relaxation  phase  was  increased.  Frequent  con- 
tractions soon  threw  the  muscles  into  tetanus.  No  reaction  of  degen- 
eration could  be  made  out.  Sensitiveness  to  pain  seemed  to  be  dimin- 
ished. 

October  18. 

The  paralysis  had  become  only  partial,  and,  with  the  exception  of 
the  muscles  of  the  foot,  the  dog  had  considerable  use  of  the  leg.  The 
foot-drop  was  as  marked  as  at  the  time  of  the  last  observation.  Sen- 
sitiveness to  pain  seemed  to  be  increased.  The  reaction  to  galvanic 
stimulation  seemed  to  be  nearly  normal.  The  length  of  the  latent 
period  was  still  increased,  but  a  greater  stimulus  was  required  to 
produce  a  maximal  contraction  than  was  needed  before.  There  was 
still  no  reaction  of  degeneration.  The  reflexes  were  still  abolished. 
The  foot  was  still  somewhat  edematous.  The  general  condition  of 
the  dog  was  good. 

October  24. 

Except  for  some  foot-drop  the  paralysis  had  disappeared,  and  the 
dog  walked  with  scarcely  any  limp.     The  electrical  reactions  showed 


ANEMIA  OF  VOLUNTARY  MUSCLES  83 

no  degeneration,  and  still  greater  stimulation  was  necessary  to  pro- 
duce a  maximal  contraction.  The  reflexes  had  not  returned,  but  the 
sensitiveness  to  pain  seemed  to  be  normal. 

October  29. 

The  foot-drop  had  disappeared.  A  slight  knee-jerk  could  be  ob- 
tained.    The  leg  was  used  without  any  difficulty. 

November  12. 

No  trace  of  the  previously  altered  functions  could  be  detected. 
The  dog  could  leap  and  play  as  well  as  ever.  Under  ether  anesthesia 
the  adductor  magnus  and  part  of  the  sciatic  nerve  were  removed.  No 
gross  changes  could  be  detected. 

Microscopical  Examination. — Evidences  of  an  old  hemorrhage 
into  the  muscle  tissue  were  found.  About  the  upper  part  of  the 
muscle  some  edema  was  present,  and  in  this  region  there  was  slight 
necrosis.  About  the  blood  vessels  were  areas  of  round  cell  infiltra- 
tion. In  many  places  the  sarcolemma  had  separated  from  the  muscle 
fiber,  apparently  as  a  result  of  previous  edema.  No  definite  signs  of 
regeneration  could  be  made  out,  and  there  did  not  seem  to  have  been 
any  marked  destruction  of  muscle  fibers. 

EXPERIMENT    17 

December  5,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  6  hours. 
The  dog  died  about  2  hours  after  the  close  of  the  experiment.  The 
autopsy  was  negative.    No.  changes  in  the  muscles  were  detected. 

EXPERIMENT    18 

December  7,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  6  hours.  At 
the  close  of  the  experiment  the  dog  was  in  good  condition. 

December  8. 

There  was  complete  paralysis  of  all  the  muscles  below  the  point 
of  constriction.  The  reflexes  could  not  be  obtained,  and  sensitiveness 
to  pain  seemed  to  be  abolished.  To  the  faradic  current  there  was  a 
delayed  reaction,  but  no  reaction  of  degeneration  could  be  made  out. 

December  15. 

The  conditions  were  about  the  same.  The  dog  was  accidentally 
killed.     No  sections  were  taken. 


84  SURGICAL  ANEMIA  AND  RESUSCITATION 

EXPERIMENT    19 

January  5,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  Yz.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  thigh  for  6  hours.  At  the 
close  of  the  experiment  the  dog  was  in  poor  condition. 

January  6. 

The  dog  died  during  the  night.  The  autopsy  revealed  no  gross 
changes  to  which  death  might  have  been  attributed.  Blocks  of  tissue 
were  removed  for  microscopical  examination. 

Microscopical  Examination. — The  sections  showed  the  presence 
of  edema,  but  there  were  no  structural  changes  present. 

EXPERIMENT    20 

January  18,  1909. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  j^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  6  hours. 
At  the  close  of  the  experiment  the  bitch  was  in  good  condition. 

January  19. 

The  general  condition  was  good.  Below  the  site  of  application  of 
the  tourniquet  there  was  almost  complete  paralysis.  The  flexors  of 
the  foot  were  most  involved,  and  the  foot-drop  was  marked.  The 
knee-jerk  was  absent. 

January  20. 

Death  occurred  during  the  night.  Blocks  of  tissue  were  taken 
for  examination. 

Microscopical  Examination. — Edema  alone  was  present. 

EXPERIMENT  21 

January  20,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  6  hours. 
The  dog  died  before  the  tourniquet  was  removed.  At  the  autopsy 
the  cause  of  death  was  undetermined.  Sections  of  the  anemic  muscles 
did  not  reveal  any  changes. 

EXPERIMENT    22 

October  14,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  6  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition. 


ANEMIA  OF  VOLUNTARY  MUSCLES  85 

October  15. 

There  was  complete  paralysis  of  all  the  muscles  below  the  point 
of  application  of  the  tourniquet.  Foot-drop  was  pronounced.  The 
reaction  to  the  galvanic  current  did  not  seem  to  be  much  altered, 
although  the  latent  period  was  increased  and  the  relaxation  phase 
somewhat  prolonged.  Sensitiveness  to  pain  seemed  to  be  much 
diminished. 

October  18. 

The  condition  seemed  to  be  about  the  same.  The  foot-drop  was 
complete,  but  the  sensitiveness  to  pain  was  increased.  On  stimulating 
with  the  galvanic  current  the  period  of  shortening  was  greatly  pro- 
longed, and  the  period  of  relaxation  irregular.  The  muscles  soon  be- 
came fatigued,  and  after  being  stimulated  for  several  minutes  would 
not  respond  at  all.  No  reaction  of  degeneration  could  be  made  out. 
On  walking  the  leg  was  dragged,  and  it  was  evident  that  voluntary 
control  was  completely  lost.    The  general  condition  was  excellent 

October  24. 

There  had  been  marked  improvement  since  the  previous  note 
was  made.  A  certain  amount  of  voluntary  muscular  control  had  re- 
turned. The  knee-jerk  was  still  absent,  and  the  toe-drop  was  as  pro- 
nounced as  before.  The  period  of  shortening  on  galvanic  stimulation 
was  prolonged,  but  not  as  much  as  before.  It  took  about  twice  as 
long  to  cause  the  muscle  to  become  tetanic.  There  was  no  reaction 
of  degeneration. 

October  29. 

Improvement  had  beeni  steady,  and  the  dog  was  found  to  have 
good  control  over  most  of  the  muscles.  The  foot-drop  was  present 
only  when  the  dog  was  tired.  The  electrical  reactions  were  about 
the  same,  with  the  exception  that  the  periods  of  both  relaxation  and 
shortening  had  become  lessened.  The  latent  period  was  still  pro- 
longed, and  the  reflexes  decreased.  There  was  no  reaction  of  de- 
generation. 

November  ii. 

All  traces  of  paralysis  had  disappeared,  with  the  exception  that 
the  knee-jerk  was  greatly  diminished.  The  electrical  reactions  were 
normal.     The  foot-drop  had  disappeared. 

November  27. 

Normal  responses  were  made  to  every  test,  the  knee-jerks  now 
being  as  active  as  in  the  other  leg.  Still  no  reaction  of  degeneration 
was  obtained.     Under  ether  anesthesia  the  dog  was  killed,  and  the 


86  SURGICAL  ANEMIA  AND  RESUSCITATION 

adductor  magnus  muscle  and  a  portion  of  the  sciatic  nerve  removed. 
The  muscle  seemed  to  be  firmer  than  normal,  and  to  contain  more 
fibrous  elements. 

Microscopical  Examination. — There  was  no  doubt  but  that  an 
increase  in  the  fibrous  elements  had  occurred.  In  many  areas  evi- 
dence of  old  hemorrhages  vi^as  present.  The  sarcolemma  w^as  thick- 
ened, and,  in  many  places,  separated  from  the  fibers.  The  number 
of  nuclei  was  increased,  and  their  arrangement  was  irregular.  There 
were  fewer  areas  of  necrosis  in  this  experiment  than  in  the  last  of 
the  five-hour  ones.     The  sciatic  nerve  showed  no  changes. 

EXPERIMENT    23 

December  12,  1908. 

Mongrel  bitch ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  thigh  for  7  hours. 
While  the  bitch  was  apparently  in  good  condition  at  the  end  of  the 
experiment,  she  was  found  dead  the  next  morning.  Blocks  of  tissue 
were  removed  for  examination. 

Microscopical  Examination. — Marked  edema,  with  extensive 
interstitial  hemorrhage,  was  found.  There  did  not  seem  to  be  any 
specific  change  in  nuclei  or  cytoplasm. 


EXPERIMENT    24 

December  15,  1908. 

Mongrel  dog ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  hind  leg  for  7  hours. 
During  the  latter  part  of  the  experiment  the  respirations  became  very 
rapid,  but  decreased  in  rate  on  giving  more  ether.  At  the  end  of  the 
experiment  the  dog  was  apparently  in  good  condition. 

December  16. 

There  was  complete  paralysis  of  the  muscles  below  the  point  of 
application  of  the  tourniquet,  with  complete  foot-drop.  The  dog 
was  unable  to  walk  at  all. 

December  18. 

The  electrical  reactions  were  normal,  but  there  was  no  improve- 
ment in  the  paralysis,  and  the  knee-jerk  could  not  be  obtained. 

December  28. 

Some  improvement  'had  appeared;  the  dog  could  walk  with 
marked  foot-drop.    The  knee-jerk  could  not  be  obtained. 


ANEMIA  OF  VOLUNTARY  MUSCLES  87 

December  30. 

There  was  voluntary  movement  in  all  of  the  muscles,  although 
less  in  the  flexors  of  the  foot  than  in  the  others. 

January  7,  1909. 

Improvement  was  marked.  The  knee-jerk  was  obtained.  The 
dog  was  killed  in  a  resuscitation  experiment. 

Microscopical  Examination. — The  sections  stained  poorly.  In 
most  areas  the  cross-striations  had  disappeared,  and,  where  present, 
they  showed  very  faintly.  In  many  of  the  fibers  KoUiker's  columns 
showed.  In  some  of  the  fibers  hyaline  degeneration  was  complete. 
In  many  places  active  regeneration  was  shown  by  the  great  increase 
in  the  number  of  nuclei. 

EXPERIMENT    25 

December  16,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  3^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  7  hours. 
At  the  close  of  the  experiment  the  dog  was  in  poor  condition,  and 
died  during  the  night. 

Microscopical  Examination. — Very  few  changes  were  found. 
The  cross-striation  was  not  prominent,  but  could  be  seen  in  most 
places.  The  muscle  fiber  and  sarcolemma  nuclei  were  well  stained. 
No  evidence  of  degenerative  processes  was  found. 


EXPERIMENT    26 

October  18,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  7  hours. 
During  the  last  hour  of  the  experiment  the  respirations  rose  to  70  per 
minute,  and  were  not  afifected  by  increasing  the  amount  of  ether. 
Tliis  rapid  rate  was  maintained  for  three  hours  after  the  experiment, 
or  four  hours  in  all.  Otherwise  the  condition  of  the  dog  at  the 
end  of  the  experiment  was  good. 

October  19. 

All  of  the  muscles  below  the  site  of  application  of  the  tourniquet 
were  paralyzed.  The  knee-jerk  was  abolished,  and  there  was  com- 
plete insensitiveness  to  pain.  Under  electrical  stimulation  the  muscles 
contracted,  but  the  latent  period  was  greatly  prolonged.  In  the 
afifected  'leg  the  period  of  shortening  was  also  much  longer  than  in 
the  other  leg.  There  was  not  the  great  variation  in  the  period  of 
relaxation  that  there  was  in  the  period  of  shortening;  the  muscles 


88  SURGICAL  ANEMIA  AND  RESUSCITATION 

were  soon  in  tetany,  so  that  little  could  be  determined.  There  was 
no  reaction  of  degeneration,  and  the  manipulations  did  not  seem  to 
cause  pain. 

October  24. 

On  this  date  there  was  some  improvement.  "While  motor  paraly- 
sis seemed  to  be  complete,  sensitiveness  to  pain  was  present.  The 
entire  foot  was  very  edematous,  and  was  dragged  on  walking.  There 
was  still  no  knee-jerk.  The  electrical  reactions  were  the  same. 
There  was  no  reaction  of  degeneration. 

October  2y. 

There  was  some  control  of  the  leg,  but  the  foot-drop  was  still 
absent.  Stimulation  with  the  galvanic  current  showed  that  the  period 
of  relaxation  had  decreased  since  the  24th,  but  that  it  was  still  pro- 
longed, and  that  there  was  the  same  disturbance  of  the  phases  of 
shortening  and  relaxation.  Three  minutes  of  repeated  stimulation 
threw  the  muscles  into  tetany,  from  which  they  did  not  recover  for 
several  minutes. 

November  5. 

While  the  foot-drop  was  still  marked  the  general  condition  of  the 
leg  had  improved.  The  periods  of  shortening  and  relaxation  were 
the  same  in  both  legs,  but  the  latent  period  was  much  increased  in 
the  affected  leg,  even  more  so  than  at  any  previous  time.  The  knee- 
jerk  was  still  absent.  Sensitiveness  to  pain  seemed  to  be  about  nor- 
mal. The  reaction  of  degeneration  was  shown  for  the  first  time,  18 
days  after  constricting  the  leg. 

November  9. 

There  was  no  apparent  improvement  in  the  involved  muscles,  and 
motor  control  seemed  to  be  completely  lost.  The  knee-jerk  was  ab- 
sent. The  reaction  of  degeneration  was  still  more  marked.  Edema 
was  still  present.  Sensitiveness  to  pain  was  still  present,  although 
there  was  no  evidence  of  any  suffering  from  pain  when  the  dog  was 
not  being  tested. 

November  15. 

The  condition  of  the  muscles  was  unchanged  as  far  as  the  reac- 
tions were  concerned.  If  anything  the  edema  was  worse  than  before. 
The  knee-jerk  was  still  absent. 

November  17. 

The  dog  seemed  to  be  suffering  from  pain.  The  edema  was  less. 
The  other  conditions  were  the  same. 


ANEMIA  OF  VOLUNTARY  MUSCLES  89 

November  25. 

The  edema  had  about  disappeared,  and  there  seemed  to  be  other 
slight  improvement. 
November  30. 

Considerable  use  of  the  leg  had  returned.  On  pricking  it  with 
a  pin  the  leg  was  drawn  away.  The  greatest  improvement  was  in  the 
electrical  reactions,  there  being  no  disturbance  of  the  periods  of 
shortening  or  relaxation,  although  the  length  of  the  latter  was  still 
increased  over  the  normal. 
December  8. 

The  foot-drop  was  but  slightly  improved,  but  the  control  of  the 
other  groups  of  muscles  was  good.  The  knee-jerk  was  still  absent, 
and  the  reaction  of  degeneration  still  persisted.  The  other  electrical 
reactions  were  about  normal.  The  dog  whined  a  great  deal,  as  if 
he  were  in  pain,  but  this  may  have  been  due  to  a  running  sore  (of 
trophic  origin?)  on  the  dorsum  of  the  foot. 
December  14. 

Voluntary  control  was  diminished  again.  The  other  conditions 
were  as  before,  except  that  the  muscles  were  more  easily  thrown  into 
tetany. 

December  27. 

In  general  the  condition  was   stationary,   except  that  voluntary 
control  was  lessened  still  further.     The  reaction  of  degeneration  was 
present,  and  the  knee-jerks  absent. 
February  24. 

At  this  date,  more  than  2  months  after  the  constriction,  the 
paralysis  of  the  muscles  below  the  point  of  application  of  the  tourni- 
quet was  complete.  The  reaction  of  degeneration  was  present,  and 
the  knee-jerk  had  not  returned.  Under  ether  anesthesia  the  adductor 
magnus  muscle  and  part  of  the  sciatic  nerve  were  removed.  The 
muscle  was  paler,  firmer,  and  smaller  than  normal.  The  nerve  was 
congested,  but  otherwise  seemed  to  be  normal. 

Microscopical  Examination. — A  great  increase  in  the  amount 
of  fibrous  tissue  had  occurred,  with  fragmentation  of  the  individual 
fibers.  For  the  most  part  the  cross-striations  were  absent.  In  many 
areas  pigmentation  had  occurred,  and  about  these  areas  there  was 
marked  necrosis.  Scattered  through  the  sections  were  areas  of  round- 
cell  infiltration  and  hemorrhage  into  the  tissues.  In  certain  areas  the 
normal  muscle  fibers  seemed  to  have  been  entirely  replaced  by  con- 
nective tissue.  The  sarcolemma  was  everywhere  thickened,  and  it 
was  often  separated  from  the  fibrils,  apparently  by  the  previously  oc- 


90  SURGICAL  ANEMIA  AND  RESUSCITATION 

curring  edema.  Everywhere  there  was  a  great  increase  of  the  mul- 
tinucleated cells,  and  these  were  arranged  irregularly  in  reference  to 
the  long  axes  of  the  muscle  fibers.  To  a  large  extent  the  condition 
was  that  of  progressive  muscular  atrophy,  which  had  undoubtedly 
passed  beyond  the  stage  where  entire  repair  could  have  taken  place. 


EXPERIMENT    27 

December  26,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  7  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition.    - 

December  27. 

Partial  paralysis. of  all  of  the  muscles  below  the  point  of  applica- 
tion of  the  tourniquet  was  present.  Foot-drop  was  present,  and  the 
knee-jerk  was  absent.  The  electrical  reactions  showed  prolongation 
of  the  latent  period,  but  otherwise  they  were  normal.  The  general 
condition  was  good. 

December  29. 

The  condition  of  the  affected  muscles  was  markedly  better.  The 
knee-jerk  and  foot-drop  were  as  before,  but  considerable  voluntary 
control  was  present.     The  latent  period  had  become  about  normal. 

January  8,  1910. 

Slight  foot-drop  was  still  present.     The  knee-jerk  had  returned. 

January  15. 

The  foot-drop  had  disappeared.  The  leg  seemed  to  be  normal  in 
every  way.  Under  ether  anesthesia  the  adductor  magnus  muscle  and 
a  portion  of  the  sciatic  nerve  were  removed  for  examination. 

Microscopical  Examination. — But  few  changes  could  be  made 
out.  The  cross-striation  was  less  apparent.  The  muscle  nuclei  had 
increased  in  number.  In  some  areas  there  was  slight  fragmentation 
and  pigment  deposition.  The  sarcolemma  was  separated  from  the 
fibrillse,  and  thickened.     The  nerve  seemed  to  be  normal. 


EXPERIMENT    28 

January  14,  1910. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  7  hours. 
At  the  close  of  the  experiment  the  dog  was  in  good  condition. 


ANEMIA  OF  VOLUNTARY  MUSCLES  91 

January  15. 

Complete  paralysis  was  present,  with  marked  foot-drop  and  loss 
of  the  knee-jerk.  The  latent  period  was  prolonged,  and  the  phases 
of  shortening  and  relaxation  were  very  irregular.  The  leg  was  very 
edematous.  The  sensitiveness  to  pain  was  greatly  diminished  and 
delayed.    There  was  no  reaction  of  degeneration. 

January  26. 

Marked  improvement  had  occurred  since  the  last  observation, 
eleven  days  previously.  The  edema  had  all  disappeared.  The  knee- 
jerk  was  present,  but  diminished.  The  electrical  reactions  showed 
improvement,  the  latent  period  being  the  same  for  both  legs.  The 
muscles  could  still  readily  be  thrown  into  tetany  by  repeated  shocks, 
it  not  being  impossible  to  do  this  with  the  sound  leg.  There  was  no 
reaction  of  degeneration  present.    The  voluntary  control  was  good. 

January  30. 

There  was  still  slight  foot-drop,  but  the  improvement  was  even 
greater.  The  electrical  reactions  were  normal,  and  the  knee-jerk 
active.  The  edema  had  returned  during  the  previous  two  days.  The 
voluntary  control  was  good. 

February  16. 

The  foot-drop  had  disappeared,  and  the  leg  seemed  to  be  normal. 

March  4. 

The  leg  seemed  to  be  perfectly  normal  in  every  way.  Under 
ether  anesthesia  the  adductor  magnus  muscle  and  part  of  the  sciatic 
nerve  were  removed. 

Microscopical  Examination. — The  muscle  fibers  stained  well, 
but  the  number  of  cross-striations  was  reduced.  In  some  areas  the 
latter  were  faint,  in  others  absent,  and  in  still  others  present  and 
normal  in  appearance.  The  nuclei  were  increased,  both  in  size  and  in 
number,  being  distributed  in  varied  relations  to  the  long  axes  of  the 
fibers.  In  certain  areas  there  was  hemorrhage  into  the  tissues  and 
round-cell  infiltration.  There  had  been  a  certain  amount  of  regenera- 
tion of  the  muscular  elements,  but  the  increase  of  the  connective 
tissue  elements  was  not  marked.  In  some  areas  the  sarcolemma  was 
thickened,  and  separated  from  the  fibrillae  by  the  previously  present 
edema.  In  fact,  a  certain  amount  of  edema  had  persisted,  but  it  was 
confined  to  an  area  near  the  point  of  application  of  the  tourniquet. 
The  nerve  was  edematous  in  places,  and,  on  cross  section,  the  indi- 
vidual fibers  were  somewhat  shrunken. 


92  SURGICAL  ANEMIA  AND  RESUSCITATION 

EXPERIMENT    29 

January  7,  1909. 

Black  and  tan  bitch ;  condition,  good.  Ether,  morphia,  q.  s.  A 
tourniquet  was  applied  to  the  upper  part  of  the  right  thigh  for  7^ 
hours.     At  the  end  of  this  time  death  occurred. 

Autopsy. — Microscopical  examination  of  sections  showed  only 
normal  muscle  as  far  as  structural  changes  were  concerned. 

EXPERIMENT    30 

January  6,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  y^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  8  hours. 
The  dog  died  during  the  night,  probably  from  the  effects  of  the  long 
anesthesia,  as  the  autopsy  revealed  no  explanation.  Sections  were 
made  from  the  muscles,  but  no  structural  changes  were  made  out. 
Evidently  the  blood  had  not  circulated  through  the  leg  again  after 
removing  the  tourniquet,  as  the  tissues  were  pale  and  the  blood  vessels 
empty. 

EXPERIMENT    31 

October  24,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  8  hours. 
At  no  time  was  there  any  variation  in  the  respiratory  rate,  and  the 
dog  was  in  good  condition  at  the  end  of  the  experiment. 

October  25. 

The  muscles  were  completely  paralyzed.  The  knee-jerk  was  lost, 
and  the  entire  leg  seemed  to  be  numb.  Marked  edema  was  present. 
As  regards  the  electrical  reactions  the  latent  period  was  prolonged, 
and  the  shortening  phase  was  both  prolonged  and  incomplete.  The 
relaxation  phase  was  also  much  prolonged,  and  the  muscles  were 
easily  thrown  into  tetany.  No  reaction  of  degeneration  could  be 
detected.    The  general  condition  was  good. 

October  27. 

The  general  condition  of  the  muscles  was  the  same,  but  the 
edema  had  increased.     Apparently  there  was  no  pain. 

November  5. 

Some  improvement  had  occurred,  as  there  was  partial  voluntary 
control  of  most  of  the  muscles,  the  foot-drop  still  being  complete. 
The  knee-jerk  was  absent,  and  the  edema  still  present.  There  was 
no  reaction  of  degeneration.  The  latent  period  was  still  prolonged, 
but  the  periods  of  shortening  and  relaxation  were  nearly  normal. 


ANEMIA  OF  VOLUNTARY  MUSCLES  93 

November  9.  . 

Steady  improvement  had  occurred.. 

November  15. 

The  knee-jerk  was  present  for  the  first  time.  The  foot-drop  was 
present  for  the  first  time,  but  only  when  the  dog  was  made  tired  by 
walking  or  running.     The  edema  had  practically  disappeared. 

November  25. 

So  far  as  could  be  determined  the  leg  was  normal  in  every  way. 

December  25. 

The  condition  was  still  normal,  the  use  of  the  leg  being  perfect. 
Under  ether  anesthesia  the  adductor  magnus  muscle  and  part  of  the 
sciatic  nerve  were  removed.  While  the  tissues  were  vascular  the 
muscle  was  much  smaller  than  the  corresponding  one  in  the ,  sound 
leg.  No  gross  changes  could  be  made  out  in  the  nerve,  and  there 
were  no  adhesions. 

Microscopical  Examination. — Many  areas  were  present  in  the 
muscle,  which  took  the  stain  faintly,  and  in  these  the  cross-striations 
had  disappeared ;  there  was  much  fragmentation,  and  the  connective 
tissue  was  much  increased.  The  sarcolemma  was  thickened  and  sep- 
arated in  many  places  by  the  generalized  edema  which  had  previously 
occurred.  Everywhere  there  was  a  great  increase  in  the  number  of 
nuclei,  and  they  were  often  arranged  irregularly  and  at  an  angle 
with  the  long  axes  of  the  fibers.  The  new  nuclei  were  irregular  and 
often  vacuolated.  In  some  places  the  muscle  fibers  were  granular, 
and  in  others  round-cell  infiltration  and  interstitial  hemorrhages  had 
occurred.  Everywhere  evidences  of  cell  proliferation  and  regenera- 
tion were  present.  The  nerve  fibers  showed  less  marked  changes, 
although  in  cross  section  they  seemed  shrunken,  and  the  connective 
tissue  seemed  to  be  increased  in  the  nerve  sheaths. 

As  a  whole  the  changes  produced  in  this  experiment  were  much 
milder  than  those  caused  in  Experiment  28,  a  seven-hour  experiment. 


EXPERIMENT    32 

February  14,  19 10. 

Mongrel  bitch ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  thigh  for  8  hours. 
Before  the  close  of  the  experiment  the  dorsalis  pedis  artery  was 
opened  in  the  foot,  and  it  was  proved  by  the  absence  of  circulation 
that  the  blood  was  shut  off  from  the  entire  leg.  On  removing  the 
tourniquet  the   blood  began   slowly  to   flow.     The   artery   was   then 


94  SURGICAL  ANEMIA  AND  RESUSCITATION 

ligated,  and  the  experiment  terminated.    The  bitch  was  in  good  con- 
dition. 

February  15. 

Complete  paralysis  was  present  with  foot-drop  and  loss  of  knee- 
jerk.  The  latent  period  was  prolonged,  and  the  phases  of  shortening 
and  relaxation  were  irregular.  There  was  no  reaction  of  degenera- 
tion. Edema  was  very  marked,  and  the  leg  seemed  to  be  numb.  Very 
few  electrical  impulses  sufificed  to  throw  the  leg  into  tetany.  The 
strength  of  current  that  would  produce  a  maximal  contraction  in  the 
sound  leg  failed  to  produce  any  contraction  whatsoever  of  the  affected 
leg.  In  the  latter  the  reaction  to  the  faradic  was  better  than  to  the 
galvanic  current. 

February  18. 

Very  slight  improvement  had  occurred,  the  condition  being  prac- 
tically the  same  as  before. 

February  23. 

The  general  condition  was  the  same.  For  the  first  time  the 
reaction  of  degeneration  was  obtained.  The  latent  period  was  shorter, 
and  the  periods  of  shortening  and  relaxation  were  more  normal. 
Edema  was  still  very  marked.     The  knee-jerk  had  not  returned. 

February  27. 

Except  that  the  reaction  of  degeneration  was  more  marked 
the  condition  was  about  the  same. 

March  14. 

The  reaction  of  degeneration  was  still  more  marked.  Voluntary 
control  was  about  the  same,  but  sensation  seemed  to  be  returning. 
A  strength  of  current  sufficient  to  cause  a  maximal  contraction  in 
the  sound  leg  caused  the  same  in  the  affected  leg.  The  edema 
was  less. 

March  ^y. 

There  had  been  some  improvement  in  the  voluntary  control,  but 
the  foot-drop  was  as  marked  as  ever.  The  reaction  of  degeneration 
was  still  present,  the  other  reactions  now  being  normal. 

April  7. 

The  improvement,  if  any,  had  been  slight,  and  the  voluntary  con- 
trol was  poor.  The  reaction  of  degeneration  had  persisted,  as  well  as 
the  foot-drop,  and  absence  of  knee-jerk 


ANEMIA  OF  VOLUNTARY  MUSCLES  95 

May  14. 

At  this  date,  three  months  after  the  application  of  the  tourni- 
quet, there  was  still  but  little  change  in  the  muscles  of  the  affected 
leg.  The  reaction  of  degeneration  had  been  present  since  its  first 
appearance.  The  practically  complete  loss  of  voluntary  control  was 
the  same,  the  foot-drop  still  being  present  and  the  knee-jerk  absent. 
The  amount  of  edema  had  varied  from  time  to  time,  and  the  tem- 
porarily lost  sensibility  had  returned,  at  least  in  part.  Under  ether 
anesthesia  the  adductor  magnus  muscle  and  part  of  the  sciatic  nerve 
were  removed.  The  gross  appearance  of  the  muscle  was  strikingly 
altered,  as  it  was  only  about  one-third  of  the  size  of  the  normal 
adductor  magnus  muscle  of  the  sound  leg.  It  was  also  much  darker 
in  color  than  normal,  from  marked  interstitial  hemorrhage,  and  was 
more  fibrous.     The  nerve  was  injected  and  thickened. 

Microscopical  Examination. — The  muscle  was  profoundly 
changed.  The  cross-striations  could  not  be  made  out  at  all,  and,  in 
fact,  in  many  areas  it  was  impossible  to  recognize  any  muscle  tissue; 
what  had  been  muscle  tissue  had  become  a  broken-down  mass.  Ex- 
tensive hemorrhages  were  everywhere,  as  was  also  edema.  The  tis- 
sues, as  a  whole,  stained  faintly.  Many  irregular,  indefinitely  ar- 
ranged nuclei  were  present.  The  sarcolemma  was  everywhere  thick- 
ened, and  separated  by  the  still-present  edema.  Round-cell  infiltra- 
tion was  marked,  and  generally  present.  The  condition  seemed 
to  be  one  of  atrophy  rather  than  of  attempted  regeneration.  The 
sciatic  nerve  showed  marked  thickening  of  the  neurilemma,  with  some 
hemorrhage  into  the  sheath.  Inside  of  the  sheath  many  vacant 
spaces  were  present,  which  seemed  to  indicate  absorption  of  por- 
tions of  the  fibers. 

EXPERIMENT    33 

January  2.2,  1909. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  Y^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  left  thigh  for  5^  hours. 
The  bitch  died  during  the  night,  probably  from  the  effects  of  the 
long  anesthesia.  The  autopsy  was  negative.  Microscopically  no 
structural  changes  were  found. 


EXPERIMENT    34 
January  22,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  8^  hours. 
The  dog  died  during  the  night,  probably  from  the  effects  of  the  ether, 


96  SURGICAL  ANEMIA  AND  RESUSCITATION 

as  the  autopsy  revealed  no   explanation.     The  sections   showed  no 
structural  changes,  only  anemia. 


EXPERIMENT    35 
January  9,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  Yz.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  p  hours. 
At  the  end  of  that  time  the  dog  was  in  good  condition. 

January  id. 

The  muscles  below  the  point  of  application  of  the  tourniquet  were 
completely  paralyzed.  The  knee  jerk  was  absent,  foot-drop  was  pres- 
ent in  marked  degree,  and  the  sensitiveness  to  pain  was  delayed  as 
well  as  diminished.  The  electrical  reactions  were  normal,  although 
there  was  less  response  to  the  faradic  current  on  the  paralyzed  than 
on  the  normal  side. 

January  ii. 

The  dog  died  during  the  night  from  undetermined  cause.  The 
sections  failed  to  reveal  any  structural  microscopic  changes  beyond 
edema  and  interstitial  hemorrhages. 


EXPERIMENT    36 
November  5,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  p  hours. 
During  the  last  part  of  the  experiment  the  respiratory  rate  rose  to 
60  per  minute,  but  at  the  end  the  dog  was  in  good  condition.  That 
there  was  no  circulation  in  the  leg  was  proved  by  opening  the  dorsalis 
pedis  artery. 

November  6. 

Complete  paralysis  and  universal  edema  were  present.  Foot- 
drop  was  complete,  the  knee-jerk  was  lost,  and  sensitiveness  to  pain 
was  greatly  diminished,  if  not  entirely  absent.  The  response  to  a 
galvanic  current  was  very  slow,  and  was  still  slower  to  a  faradic 
current.  A  much  greater  impulse  was  required  to  produce  a  maximal 
contraction  in  the  affected  than  in  the  sound  leg.  The  latent  period 
of  contraction  was  much  prolonged,  the  phase  of  shortening  was 
both  prolonged  and  incomplete,  and  the  phase  of  relaxation  pro- 
longed and  irregular.  Tetany  was  quickly  caused  by  a  few  rapidly 
repeated  impulses.     No  reaction  of  degeneration  was  present. 


ANEMIA  OF  VOLUNTARY  MUSCLES  97 

November  9. 

Except  that  sensitiveness  to  pain  had  returned  the  condition  was 
practically  the  same  as  it  was  three  days  previous. 

November  15. 

There  had  been  some  improvement.  While  the  foot-drop  was  as 
marked  as  before  there  was  some  power  in  the  other  voluntary 
muscles.  The  knee-jerk  was  absent,  and  the  edema  less.  The  reac- 
tion of  degeneration  was  present. 

November  17. 

The  reaction  of  degeneration  was  more  marked.  The  knee-jerk 
was  absent.  Sensitiveness  to  pain  was  increased.  The  voluntary 
control  was  better. 

November  26. 

As  a  whole  the  condition  had  been  about  stationary.  The  reac- 
tion of  degeneration  was  very  marked,  but  the  other  electrical  reac- 
tions were  nearly  normal.    The  knee-jerk  had  not  returned. 

December  5. 

There  had  been  no  appreciable  change,  except,  perhaps,  less  vol- 
untary control  than  before.     Sensitiveness  to  pain  was  about  normal. 

January  14,  19 10. 

The  condition  was  about  the  same,  being  clearly  one  of  pro- 
gressive muscular  atrophy.  The  leg  was  paralyzed.  The  knee-jerk 
was  absent,  and  the  reaction  of  degeneration  marked.  Under  ether 
anesthesia  the  adductor  magnus  muscle  and  part  of  the  sciatic  nerve 
were  removed.  The  muscular  tissue  seemed  to  be  very  fibrous  and 
harder  than  normal.     The  nerve  showed  no  gross  changes. 

Microscopical  Examination. — The  fibrous  tissue  was  greatly 
increased  in  all  parts  of  the  sections.  Fragmentation  of  the  muscle 
fibers  was  marked,  the  cross-striations,  to  a  large  extent,  being  absent, 
and,  when  present,  being  very  indistinct.  The  sarcolemma  was  thick- 
ened and  separated  from  the  fibrillse  in  many  places  by  edema.  In 
various  areas  hemorrhage  into  the  tissues  had  occurred,  particularly 
along  the  course  of  the  blood  vessels  themselves.  The  blood  vessels 
were  much  altered.  The  nerve  trunk  showed  marked  breaking-up  of 
the  bundles  and  shrinkage  of  the  fibers.  Vacuolated  areas  were 
numerous. 

EXPERIMENT    37 

April  24,  1910. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  p  hours. 


98  SURGICAL  ANEMIA  AND  RESUSCITATION 

At  the  close  of  the  experiment  the  dorsalis  pedis  artery  was  exposed 
and  opened.  A  slight  continuous  flow  of  blood  resulted,  which 
showed  that  the  circulation  had  not  been  entirely  shut  off.  At  this 
time  the  dog  was  in  good  condition. 

April  25. 

All  of  the  muscles  of  the  affected  leg  were  completely  paralyzed, 
with  foot-drop  and  loss  of  knee-jerk.  The  leg  was  very  edematous 
and  very  numb.  The  electrical  reactions  showed  marked  prolonga- 
tion of  the  latent  period,  and  delayed  and  irregular  phases  of  shorten- 
ing and  relaxation.    There  was  no  reaction  of  degeneration. 

April  29. 

The  extensor  muscles  were  completely  paralyzed,  but  the  volun- 
tary control  of  the  others  was  present  to  a  certain  extent.  Consider- 
able tenderness  was  present,  as  the  dog  snapped  at  anybody  who 
tried  to  touch  him.  The  knee-jerk  was  absent.  It  was  impossible  to 
determine  the  electrical  reactions,  on  account  of  the  pain  that  the 
attempt  caused. 

May  12. 

Paralysis  was  almost  entirely  absent,  the  foot-drop  showing  only 
after  the  dog  was  fatigued  by  running  around  the  room.  The  knee- 
jerk  was  still  absent,  no  reaction  of  degeneration  could  be  obtained. 
The  latent  period  was  the  same  in  both  legs.  Much  of  the  edema  had 
disappeared. 

May  17. 

The  leg  was  normal  in  every  way. 

May  26. 

The  leg  was  still  completely  normal  as  far  as  function  was  con- 
cerned. Under  ether  anesthesia  the  adductor  magnus  muscle  and  part 
of  the  sciatic  nerve  were  removed.  The  muscle  was  somewhat 
smaller  than  normal,  and  firmer. 

Microscopical  Examination. — The  muscle  bundles  stained  rath- 
er faintly  with  less  prominence  of  the  cross-striations  than  normal. 
In  one  small  area  there  was  marked  fragmentation,  while  interstitial 
hemorrhages  were  numerous.  In  some  places  there  was  round-cell 
infiltration.  The  blood  vessels  had  much  thickened  walls.  About 
some  of  them  amyloid  changes  had  taken  place.  No  areas  suggesting 
infarction  were  found.  On  the  whole  the  changes  were  irregularly 
distributed,  in  marked  contrast  to  those  found  in  some  of  the  pre- 
ceding experiments.    This  was  probably  because  the  circulation  had 


ANEMIA  OF  VOLUNTARY  MUSCLES  99 

not  been  entirely  cut  off.  On  account  of  the  microscopic  changes  it 
was  difficult  to  account  for  the  rapid  return  of  voluntary  control  of 
the  leg. 

EXPERIMENT    38 

April  2,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  y^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  hind  leg  for  IQ 
hours.  At  the  close  of  the  experiment  the  condition  of  the  dog  was 
good. 

April  3. 

The  muscles  below  the  point  of  application  of  the  tourniquet  were 
completely  paralyzed.  Sensitiveness  to  pain  was  both  diminished  and 
delayed.  The  reflexes  were  abolished.  Reaction  to  the  faradic  cur- 
rent was  somewhat  sluggish,  but  was  normal  to  the  galvanic  current. 

April  8. 

Slight  improvement  of  function  had  occurred.  Sensation  was 
more  acute.    The  response  to  the  faradic  current  was  more  active. 

April  16. 

There  had  been  slight  continued  improvement,  the  flexor  muscles 
of  the  paw  showing  the  least.     Sensation  was  acute. 

May  7. 

The  condition  was  apparently  unchanged. 

May  16. 

Little  or  no  improvement  had  occurred  during  the  previous  nine 
days.  While  voluntary  movement  was  present  in  all  of  the  involved 
muscles  it  was  much  less  than  in  the  normal  leg.  The  electrical  re- 
actions were  normal.  The  knee-jerk  was  present  but  diminished. 
Under  ether  anesthesia  the  dog  was  killed,  and  the  adductor  magnus 
muscle  and  part  of  the  sciatic  nerve  were  removed. 

Microscopical  Examination. — Everywhere  through  the  sec- 
tions there  was  marked  atrophy  of  the  muscle  fibers,  with  evidence 
of  formation  of  new  muscle  cells.  In  the  old  fibers  the  cross-stria- 
tions  were  very  indistinct,  while  in  the  new  they  were  very  distinct. 
In  certain  areas  numerous,  large,  irregularly  shaped,  more  or  less 
vesiculated  and  granular  nuclei  were  present.  General  fragmenta- 
tion was  absent,  such  as  there  was  being  confined  to  a  few  small 
areas.  The  muscle  cell  proliferation  seemed  to  have  been  most  active 
around  the  larger  blood  vessels.  The  sarcolemma  was  everywhere 
much  thickened.  In  some  areas  extensive  hemorrhage  and  pigmen- 
tation had  occurred. 


lOO  SURGICAL  ANEMIA  AND  RESUSCITATION 

ESPERIMENT    39 

November  5,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  appHed  to  the  upper  third  of  the  left  thigh  for  10  hours. 
During  the  latter  part  of  the  experiment  the  respiratory  rate  was 
greatly  increased  up  to  76  per  minute,  and  remained  at  this  rate  for 
three  hours  afterward.  Otherwise  the  condition  was  good.  Just  be- 
fore the  tourniquet  was  removed,  opening  the  dorsalis  pedis  artery 
showed  that  the  cessation  of  circulation  had  been  complete.  Ten 
minutes  after  removing  the  tourniquet  the  circulation  seemed  to  be  as 
vigorous  as  ever. 

November  6. 

All  of  the  muscles  below  the  point  of  application  of  the  tourni- 
quet were  completely  paralyzed.  The  leg  was  edematous,  with  marked 
swelling,  and  numb.  The  latent  period  of  contraction  was  greatly 
prolonged,  while  the  periods  of  shortening  and  relaxation  were  irreg- 
ular.    Fatigue  soon  followed  the  stimulation. 

November  7. 

The  dog  was  found  dead  this  morning,  having  been  dead  for 
several  hours.  The  autopsy  showed  the  presence  of  pneumonia.  The 
muscles  were  very  edematous,  and  there  had  been  interstitial  hemor- 
rhages. The  sciatic  nerve  was  also  edematous,  and  hemorrhages  had 
occurred  along  its  course. 


EXPERIMENT    40 

April  24,  1910. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  10  hours. 
At  the  close  of  the  experiment  opening  the  dorsalis  pedis  artery 
showed  that  there  was  no  circulation  present.  Toward  the  latter  part 
of  the  time  the  respiratory  rate  rose  from  33  to  95  per  minute.  The 
respiration  was  very  labored,  and  neither  rate  nor  character  seemed 
to  be  dependent  on  the  depth  of  anesthesia.  This  condition  persisted 
for  about  four  hours  after  the  experiment. 

April  25. 

As  usual  there  was  complete  paralysis,  with  marked  foot-drop 
and  loss  of  knee-jerk.  The  leg  was  very  edematous,  and  sensitiveness 
to  pain  seemed  to  have  been  completely  lost.  The  electrical  reactions 
showed  a  marked  increase  in  the  latent  period  of  contraction,  as  well 
as   irregular  and  delayed  phases  of  shortening  and  relaxation.     No 


ANEMIA  OF  VOLUNTARY  MUSCLES  loi 

reaction  of  degeneration   was  present.     The   muscles   were  soon   fa- 
tigued and  then  thrown  into  tetany  by  continued  stimulation. 

April  28. 

The  conditions  were  the  same  except  for  an  increase  in  the 
amount  of  edema. 

May  2. 

There  had  been  a  slight  return  of  voluntary  control.  The  edema 
was  less.  The  foot-drop  was  still  complete,  and  the  knee-jerk  absent. 
There  was  no  reaction  of  degeneration.  A  much  greater  stimulus 
was  required  to  produce  the  minimal  contraction  on  the  affected  side 
than  the  maximal  contraction  on  the  sound  side.  No  reaction  of 
degeneration  was  present. 

May  8. 

The  reaction  of  degeneration  was  present. 

May  14. 

The  condition  seemed  to  be  stationary  in  regard  to  voluntary 
muscular  control.  The  reaction  of  degeneration  was  much  more 
marked.  The  edema  had  almost  disappeared.,  and  sensitiveness  to 
pain  was  very  acute. 

May  27. 

The  reaction  of  degeneration  was  still  more  marked.  The  knee- 
jerk  had  not  returned. 

June  15. 

The  leg  had  become  much  smaller  in  size.  On  making  a  urinary 
examination  glucose  was  found  to  be  present,  but  how  long  it  had 
been  present  was  not  known,  as  this  was  the  first  time  that  the  test 
had  been  made. 

June  16. 

By  the  polariscope  0.4  per  cent,  of  sugar  was  present  in  the  urine. 

June  18. 

Condition  the  same  locally,  with  the  dog  in  very  poor  general 
condition. 

June  24. 

The  dog  died  during  the  night.  The  autopsy  failed  to  show  any 
suggestive  lesions.  The  glycosuria  had  been  present  continually 
since  it  was  first  detected,  the  percentage  of  sugar  varying  much  from 
day  to  day.  The  last  examination  of  the  muscles  was  made  on  the 
2ist  inst.,  and  there  was  then  no  apparent  change.     The  reaction  of 


I02  SURGICAL  ANEMIA  AND  RESUSCITATION 

degeneration  was  very  marked,  the  knee-jerk  had  not  returned,  the 
size  was  reduced  two-thirds,  there  had  been  extensive  interstitial 
hemorrhage,  and  the  muscles  were  hard.  The  sciatic  nerve  was 
hemorrhagically  injected. 

Microscopical  Examination. — Many  profound  changes  had  oc- 
curred, and  in  places  it  was  difficult  to  tell  that  the  tissue  had  ever 
been  muscle.  The  cross-striations  were  often  completely  obliterated, 
and  were  nowhere  distinct.  Fragmentation  was  almost  universally 
present.  The  nuclei  were  greatly  increased  in  size  and  number,  and 
bore  no  definite  relation  to  the  axes  of  the  fibers.  The  sarcolemma 
was  greatly  thickened  and  very  edematous.  Round-cell  infiltration 
was  everywhere  present.  The  hemorrhages  in  evidence  macroscopi- 
cally  were  still  more  so  microscopically.  The  nerve  showed  fibrous 
degeneration.  The  neurilemma  was  much  thickened  and  edematous. 
On  cross-section  the  individual  fibers  were  seen  to  be  atrophied,  and 
often  entirely  absent,  as  shown  by  the  vacant  space  which  they  had 
previously  occupied. 

EXPERIMENT    41 

April  27,  1910. 

Mongrel  dog;  condition,  good.  Ether,  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  right  thigh  for  10  hours. 
Absence  of  circulation  was  proved  by  opening  the  dorsalis  pedis 
artery.  At  the  close  of  the  experiment  the  condition  of  the  dog  was 
good. 

April  28. 

The  dog  died  during  the  night  from  aspiration  pneumonia.  In 
the  gross  the  muscles  showed  edema  without  interstitial  hemorrhage, 
but  the  microscopical  examination  showed  no  structural  changes. 

EXPERIMENT    42 

April  25,  1910. 

Mongrel  dog ;  condition,  good.  Ether ;  morphia,  q.  s.  A  tourni- 
quet was  applied  to  the  upper  third  of  the  left  thigh  for  10  hours. 
Absence  of  circulation  was  proved  by  opening  the  dorsalis  pedis 
artery.    At  the  close  of  the  experiment  the  dog  was  in  good  condition. 

April  26. 

Complete  paralysis  was  present,  with  foot-drop  and  loss  of  knee- 
jerk.  The  leg  was  very  edematous  and  numb.  The  latent  period  of 
contraction  was  increased,  and  the  phases  of  shortening  and  relaxa- 
tion were  irregular.  The  muscles  were  easily  fatigued,  and  soon 
passed  into  tetany.     No  reaction  of  degeneration  could  be  made  out. 


ANEMIA  OF  VOLUNTARY  MUSCLES  103 

April  28. 

Sensitiveness  to  pain  had  returned. 

May  2. 

Some  improvement  had  occurred.  The  dog  could  walk  without 
much  trouble.  The  foot-drop  was  still  present  and  the  knee-jerk 
absent.    There  was  no  reaction  of  degeneration. 

May  25. 

As  far  as  could  be  determined  no  trace  of  the  effects  of  the 
anemia  was  left.     The  electrical  reactions  were  normal. 

May  27. 

Condition  the  same.  Under  ether  anesthesia  the  adductor  magnus 
muscle  and  part  of  the  sciatic  nerve  were  removed.  The  gross 
examination  failed  to  show  any  changes. 

Microscopical  Examination. — There  was  considerable  intersti- 
tial hemorrhage  and  round-cell  infiltration.  In  places  the  cross- 
striations  did  not  show  plainly,  while  in  others  they  were  distinct. 
Variable  degrees  of  fragmentation  were  present.  There  was  a  great 
increase  in  the  number  of  nuclei,  and  thei.-  position  was  without  rela- 
tion to  the  long  axes  of  the  fibers.  The  blood  vessels  were  greatly 
thickened,  and  some  of  them  were  almost  occluded.  No  infarcts  were 
found.  The  sciatic  nerve  had  a  thickened  neurilemma.  The  indi- 
vidual fibers  were  less  distinct  than  normal.  As  a  whole  the  condi- 
tion was  that  of  recovery  from  a  degree  of  anemia  which  had  not 
been  severe  enough  to  cause  permanent  changes.  Why  this  should 
be  so,  when  such  marked,  changes  followed  lesser  intervals  of  anemia, 
is  difficult  to  explain. 

EXPERIMENT    43 
April  25,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  y^.  A  tour- 
niquet was  applied  to  the  upper  third  of  the  right  thigh  for  16  hours. 
At  the  end  of  this  time  the  dog  was  in  good  condition. 

April  26. 

All  of  the  muscles  below  the  point  of  application  of  the  tourni- 
quet were  paralyzed.  The  reflexes  could  not  be  obtained,  sensitive- 
ness to  pain  was  delayed,  if  not  entirely  absent,  and  the  reaction  to 
the  faradic  current  was  less  than  in  the  normal  leg.  The  reaction 
to  the  galvanic  current  was  nominal. 

April  27. 

The  condition  was  about  the  same  in  the  leg.  The  general  con- 
dition was  excellent. 


I04  SURGICAL  ANEMIA  AND  RESUSCITATION 

May  3. 

There  was  slight  improvement.  The  response  to  the  faradic 
current  was  greater,  as  well  as  sensitiveness  to  pain. 

May  5. 

Slight  voluntary  muscular  movement  was  present.  The  knee- 
jerk  could  not  be  elicited. 

May  8. 

Voluntary  control  had  continued  to  return,  the  flexors  of  the 
paw  showing  the  least  improvement. 

May  15. 

The  knee-jerk  had  partially  returned.  The  electrical  reactions 
were  normal.     On  walking  the  dog  dragged  the  limb. 

May  25. 

Since  the  last  note  there  had  not  been  much  improvement  in 
the  paralysis,  the  condition  seeming  to  be  at  a  standstill. 

June  i. 

Very  slight  improvement  had  occurred. 

June  id. 

There  was  still  marked  paralysis  present.  The  knee  jerk  was 
present,  but  it  was  very  sluggish.  The  electrical  reactions  were  nor- 
mal. The  dog  was  chloroformed,  and  the  adductor  magnus  muscle 
and  part  of  the  sciatic  nerve  removed. 

Microscopical  Examination. — The  muscles  were  generally 
atrophied  with  almost  complete  loss  of  the  cross-striation.  Frag- 
mentation was  extreme,  and  the  fibrillse  were  all  but  destroyed. 
Throughout  the  section  there  were  many  cells  containing  large  granu- 
lar nuclei.  The  latter  were  indefinitely  arranged.  In  many  places 
the  infiltration  of  leukocytes  had  been  very  great,  and  in  some  areas 
there  was  pigmentation,  resulting  from  interstitial  hemorrhages.  In 
other  areas  numerous  infarcts  were  found,  with  necrosis  surrounding 
them.  There  did  not  seem  to  be  the  proliferation  of  the  fixed  cells 
that  would  be  expected.  The  sarcolemma  was  everywhere  thickened, 
and,  in  some  areas,  so  much  so  that  the  muscle  fibers  were  practically 
obliterated.  As  a  whole  the  sections  seemed  to  show  that  regenera- 
tion had  not  had  time  to  start,  and  that  general  atrophy  alone  had 
taken  place. 


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Recovery 

Recovery 

Recovery 

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Recovery 

Recovery 

Recovery 

Recovery 

Recovery 

Recovery 

Death  after  2  weeks  from  un- 
known cause 

Nearly  well  after  2  weeks,  then 
killed 

Died  during  night — no  micro- 
scopic changes 

Recovery 

Died  during  night — no  micro- 
scopic changes 

Condition  same  after  8  days, 
dog  killed 

Died  during  night;  edema 
alone  present 

Death  on  2nd  day.  Edema 
only  change 

Death  before  tourniquet  was 
removed.  No  microscopic 
changes 

Recovery  of  function 

Died  during  night— no  micro- 
scopic changes 

Almost  complete  recovery,  22 
days,  dog  then  killed 

Died  during  night — no  micro- 
scopic changes 

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106 


ANEMIA  OF  VOLUNTARY  MUSCLES  107 

CONCLUSIONS. 

1.  Complete  arrest  of  the  circulation  of  an  extremity  for 
more  than  two  hours  is  not  wholly  safe. 

2.  The  longer  the  anemia  beyond  two  hours  the  greater 
is  the  degree  of  temporary  or  permanent  paralysis,  and  anemia 
of  seven  hours  or  more  results  in  permanent  paralysis. 

3.  Good  functional  recovery  occurs  sometimes,  even 
though  there  may  be  a  certain  amount  of  destruction  of  muscle 
fibers.  It  has  not  been  definitely  ascertained  whether  paraly- 
sis followed  by  apparent  functional  recovery  might  not  in  the 
course  of  months  be  followed  by  further  and  permanent  im- 
pairment of  function. 


CHAPTER  IV 

ANEMIA    OF    VOLUNTARY    MUSCLES  :     CLINICAL    OBSERVATIONS. 
OCCLUSION    OF   THE   ABDOMINAL    AORTA   IN    MAN 

Clinical  experience  has  shown  that  in  the  human  being 
the  abdominal  aorta  may  be  partly  or  wholly  occluded  by  em- 
bolism, by  thrombosis,  by  pressure,  or,  in  case  of  operative 
necessity,  by  ligation,  but  whatever  its  cause,  the  occurrence 
of  this  condition  is  rare.  It  is  of  interest,  however,  on  ac- 
count of  the  interference  with  the  blood  supply  of  the  lower 
extremities  and  the  variety  of  tissues  affected  and  the  diffi- 
culty of  establishing  collateral  circulation  w-hich  can  efficiently 
take  the  place  of  the  largest  blood  vessel  in  the  body. 

In  the  absence  of  personal  clinical  experience,  and  in 
order  to  base  this  study  as  directly  as  possible  on  observed 
facts,  fifty  cases  of  obstruction  of  the  abdominal  aorta  were 
collected  at  random  from  the  literature  of  the  subject.  No 
attempt  was  made  to  include  every  reported  case ;  A\"elch  alone 
had  collected  59  up  to  the  year  1899.  The  list  includes  only 
cases  reported  after  1850.  There  were  36  of  probable  embo- 
lism, 5  of  thrombosis,  and  9  of  ligation.  (For  the  technical 
problems  of  ligation  the  reader  is  referred  particularly  to 
the  article  by  W.  W.  Keen.)  In  the  following  pages,  unless 
it  is  specifically  mentioned  that  the  9  cases  of  ligation  were 
included,  reference  is  made  only  to  the  cases  of  embolism  and 
thrombosis. 

In  regard  to  the  influence  of  sex  and  age  upon  the  occur- 
rence of  obstruction  of  the  abdominal  aorta  by  embolism  or 

108 


OCCLUSION  OF  THE  ABDOMINAL  AORTA 


109 


by  thrombosis,  it  was  found  that  in  40  cases  there  were  21 
females  and  19  males,  and  that  most  of  the  cases  fell  between 
the  ages  of  20  and  60  years,  the  minimum  age  being  19  and 
the  maximum  64  years.  The  exact  age  distribution  by  decades 
is  shown  in  the  following  table  : 

Age  Grouping  by  Decades 


10-19  years 

I  case. 

20-29  years 

8  cases. 

30-39  years 

8  cases. 

40-49  years 

10  cases. 

50-59  years 

8  cases. 

60-69  years 

2  cases. 

Age  not  stated 

3  cases. 

40  cases. 

Infection  of  one  kind  or  another  is  the  primary  cause  of 
almost  all  cases  of  embolism  or  thrombosis  of  the  abdominal 
aorta — acute  articular  rheumatism  and  erysipelas  being  the 
principal  definite  causes,  next  to  arteriosclerosis,  and  the 
rather  indefinite  infections  following  childbirth.  As  would 
be  expected  the  secondary  cause — almost  without  exception — 
is  found  in  the  effect  of  these  infections  upon  the  endothelium 
of  the  heart  and  of  the  aorta  itself.  In  one  of  Duncan's  cases 
death  occurred  between  3  and  4  days  after  the  onset  of  em- 
bolism, which  began  5  days  after  a  childbirth.  At  the 
autopsy  the  heart  was  found  to  be  "perfectly  normal"  (from 
Hervieux).  If  no  abnormality  were  overlooked,  and  infec- 
tion may  be  ruled  out,  it  is  difficult  to  understand  just  how 
embolism  resulting  in  gangrene  of  both  legs  could  be  brought 
about.  The  capillaries  in  the  pulmonic  circulation  would  pre- 
vent any  coagulum  from  the  venous  sinuses  of  the  uterus  from 


no  SURGICAL  ANEMIA  AND  RESUSCITATION 

passing  into  the  left  side  of  the  heart.  With  a  normal  heart  it 
is  very  improbable  that  even  a  very  acute  infectious  process 
would  cause  thrombosis  in  so  short  a  time  except  possibly  in 
the  pulmonary  veins — an  occurrence  which  might  have  been 
overlooked  by  Duncan. 

The  only  exception  which  was  found  to  the  general  rule 
that  obstruction  of  the  abdominal  aorta  is  of  endovascular 
origin  was  in  one  of  Bristowe's  cases.  In  this  case  the  aorta 
was  completely  obstructed  at  the  level  of  the  celiac  axis  by  the 
pressure  of  a  thoracic  aneurysm  which  forced  it  against  the 
vertebrae.  Even  here  one  would  naturally  conjecture  whether 
the  aortic  stream  might  not  have  been  first  slowed  by  partial 
obstruction  resulting  from  pressure  by  coagulum  formation  in 
the  aneurysm,  and  the  subsequent  release  of  an  embolism;  the 
resultant  backing-up  of  pressure  forcing  the  aneurysm  against 
the  aorta  with  still  more  force  to  complete  the  pathologic 
circle. 

Including  the  5  cases  of  thrombosis  there  were  37  cases 
in  which  the  endovascular  obstruction  had  evidently  occurred 
primarily  at  the  bifurcation  of  the  aorta.  In  some  of  these 
the  coagulum  extended  a  considerable  distance  above  and  be- 
low this  point,  filling  the  aorta  as  high  even  as  the  diaphragm 
above  and  extending  for  a  greater  or  less  distance  into  its 
ramifications  below.  In  Pozzi's  thrombosis  case  the  artery 
was  said  to  have  been  filled  throughout  its  entire  extent  even 
down  to  the  feet  in  the  lower  branches. 

In  2  cases  the  point  of  obstruction  was  at  the  level  of  the 
celiac  axis.  One  was  the  above-mentioned  case  of  Bristowe's. 
In  the  other,  also  one  of  Bristowe's  cases,  and  one  in  which 
a  thoracic  aneurysm  was  present,  it  was  not  stated  whether  the 
obstruction  was  localized  or  whether  a  coagulum  had  extended 
up  from  the  bifurcation  as  a  sequence  to  the  lodgment  of  an 
embolism  from  the  aneurysmal  sac.    Finally,  in  a  third  case  of 


OCCLUSION  OF  THE  ABDOMINAL  AORTA  m 

Bristowe's,  there  was  obstruction  at  the  level  of  the  superior 
mesenteric  artery,  an  aneurysm  of  the  thoracic  aorta  being 
present,  and  also  a  second  aneurysm,  the  size  of  a  filbert,  at 
the  opening  of  the  superior  mesenteric  artery.  The  latter  may 
have  been  caused  by  the  backing-up  of  pressure  after  obstruc- 
tion of  the  aorta  rather  than  have  been  simultaneously  present 
with  the  other  aneurysm. 

In  the  40  cases  of  obstruction  not  included  in  the  9  ligation 
cases  and  the  above  cases  of  Bristowe's,  the  associated  condi- 
tions were  as  follows:  cardiac  disease,  30;  aortitis,  4; 
aneurysm,  3;  syphilis  (no  more  definite  statement  made),  i; 
postoperative  volvulus  (thrombosis  case),  i;  subsequent  to 
childbirth,  heart  normal,  i. 

Among  the  30  cardiac  cases  the  distribution  according  to 
the  most  important  lesion  was  as  follows:  endocarditis  with 
mitral  stenosis,  13;  endocarditis  without  mitral  stenosis,  14; 
cardiac  cases  with  indefinite  diagnosis,  3.  According  to  these 
figures  mitral  stenosis  apparently  has  not  played  as  important 
a  part  as  has  been  ascribed  to  it  by  other  observers,  although 
this  lesion  is  present  frequently. 

In  regard  to  the  13  cases  of  endocarditis  with  mitral 
stenosis  the  underlying  infectious  process  was  not  stated  in  so 
many  cases  that  the  details  of  the  exceptions  are  not  worth 
recording.  Among  the  14  cases  of  endocarditis  without 
mitral  stenosis  there  were  5  postpuerperal  cases,  3  with  acute 
articular  rheumatism,  2  with  erysipelas,  i  with  pneumonia,  i 
with  typhus,  and  2  in  which  the  associated  condition  was  not 
stated. 

In  the  great  majority  of  the  cardiac  cases  the  observation 
that  emboli  have  started  from  some  portion  of  the  left  heart  is 
confirmed  by  finding  on  the  auricular  or  ventricular  wall 
(much  more  commonly  the  former)  a  portion  of  an  old  throm- 
bus, or  the  place  f  rom.  which  a  thrombus  has  become  detached. 


112  SURGICAL  ANEMIA  AND  RESUSCITATION 

Doubtless  in  the  cases  of  mitral  stenosis  the  partial  obstruction 
of  the  flow  through  the  mitral  valve  favors  clotting  in  the  left 
auricle.  In  some  cases  the  presence  of  a  thrombus  on  the  wall 
of  the  auricle  led  to  the  formation  of  a  cup-shaped  pocket  into 
which  it  was  possible  in  a  few  instances  to  fit  the  embolus 
taken  post  mortem  from  its  lodging  place  at  the  bifurcation  in 
the  aorta.  In  other  cases  microscopic  comparison  of  the  em- 
bolus and  of  the  coagulum  remaining  in  the  left  side  of  the 
heart  has  shown  identity  of  structure. 

It  is  of  considerable  significance  that  embolism  of  the 
abdominal  aorta  may  be  associated  with  multiple  emboli  of 
other  vessels,  particularly  those  of  the  kidneys  and  spleen 
(see  Meynard,  Tutschek,  Barie  and  du  Castel,  and  others).  In 
one  case  the  splenic  artery  was  obliterated  by  an  embolus,  in 
another  three  of  the  lumbar  arteries,  while  Lauenstein  in  one 
of  his  cases  found  areas  of  softening  in  the  cerebrum.  From 
the  standpoint  of  operative  interference  the  occurrence  of 
such  emboli  might  in  itself  be  prohibitive. 

The  cardinal  symptoms  of  embolism  of  the  abdominal 
aorta  are  as  follows :  ( i )  sudden  severe  pain  in  the  legs, 
(2)  sudden  paraplegia,  and  (3)  general  collapse.  From 
the  clinical  histories  of  the  above-mentioned  cases  it  seems 
improbable  that  embolism  ever  occurs  without  pain,  and  it 
is  certainly  difficult  to  believe  that  it  could  occur  in  a  stream 
of  the  size  and  force  of  that  in  the  aorta  without  immediate 
symptoms  indicating  its  onset.  In  partial  confirmation  of  this 
is  the  fact  that  out  of  41  cases  studied  the  onset  of  symptoms 
in  29  was  sudden,  while  in  8  only  was  it  late,  and  in  4  cases  no 
statement  regarding  the  time  of  onset  is  made.  Included 
among  the  8  cases  with  slow  onset  were  5  cases  of  thrombosis ; 
a  case  diagnosed  as  embolism,  although  there  was  reasonable 
doubt  as  to  whether  it  might  not  have  been  thrombosis  with 
final  sudden  obstruction ;  and  another  in  which  the  abdominal 


OCCLUSION  OF  THE  ABDOMINAL  AORTA  113 

pain  was  sudden  but  the  leg  symptoms  were  slow  in  develop- 
ing, thus  suggesting  embolism  with  only  partial  obstruction  at 
first;  and,  finally,  a  case  in  which  the  symptoms  of  gangrene 
were  delayed  considerably  in  their  appearance.  It  seems  prob- 
able that  where  the  onset  of  symptoms  is  delayed  in  cases 
which  are  clearly  not  thrombotic  in  character  there  is  incom- 
plete obstruction,  even  if  it  be  temporary  only.  It  stands  to 
reason  that  the  force  of  the  heart-beat  would  tend  to  hammer 
an  embolus  farther  and  farther  into  the  inadequate  path — at 
least  until  development  of  the  collateral  circulation  could  re- 
lieve part  of  the  pressure. 

In  thrombosis  the  symptoms  most  frequently  follow  ar- 
teriosclerotic changes  in  the  aortic  wall.  They  may  start  so 
slowly  that  it  is  impossible  to  say  at  exactly  what  time  they 
began ;  they  may  develop  more  or  less  slowly,  and  yet,  at  the 
critical  moment,  the  completion  of  the  obstruction  may  cause 
onset  to  seem  to  be  sudden  after  all.  In  either  embolism  or 
thrombosis  the  relation  of  the  obstruction  to  the  openings  of 
the  renal  arteries  is  important.  These  are  more  likely  to  be 
occluded  in  the  latter  than  in  the  former. 

In  regard  to  the  character  of  the  pain,  it  may  be  agonizing, 
may  cause  the  patient  to  fall  to  the  ground  as  from  a  knife 
thrust,  and,  while  usually  in  the  legs,  may  be  in  the  lumbar 
region  or  the  abdomen.  The  pain,  as  with  all  the  other  symp- 
toms of  this  affliction,  doubtless  varies  considerably  with  the 
completeness  of  the  obstruction  of  the  aorta.  If  the  obstruc- 
tion be  limited  to  the  immediate  vicinity  of  the  bifurcation  it 
hardly  seems  as  if  it  could  be  connected  with  anemia  of  the 
spinal  cord,  but  rather  as  if  it  were  caused  by  local  hyperemia 
and  pressure  in  the  extremities,  such  as  is  produced  when  a 
tourniquet  is  applied  too  tightly.  With  a  high  obstruction 
the  spinal  arteries  would  be  involved  in  proportion  to  its  ex- 
tent.    With  incomplete  obstruction  paresthesias  of  different 


114  SURGICAL  ANEMIA  AND  RESUSCITATION 

varieties  may  be  the  forerunners  of  pain,  or  would  probably 
be  present  later  in  case  the  collateral  circulation  should  be 
partially  established.  Occasionally  the  pain  may  be  spasmodic 
in  nature.  Pain  was  stated  to  have  been  present  at  some  time 
in  the  course  of  the  affliction  in  32  out  of  50  cases  studied 
(ligation  cases  included),  and  no  statement  either  way  was 
made  about  the  remaining  18  cases. 

In  regard  to  paralytic  changes  in  the  legs  the  problem  rests 
on  the  fundamental  law  of  anemia  that  the  disturbance  varies 
directly  with  the  degree  of  anemia  and  its  duration.  All  de- 
grees of  disturbance  may  be  found  at  some  time  or  other,  from 
moderate  paresthesia  up  to  complete  sensory  and  motor  paral- 
ysis. Including  the  ligation  cases,  out  of  the  39  cases  in  which 
statements  were  made  as  to  motor  paralysis  of  greater  or  less 
degree,  in  36  it  was  present  and  in  3  absent.  In  37  cases 
sensory  paralysis  of  greater  or  less  degree  was  present  and  in 
3  absent.  Coldness  of  the  legs  was  present  in  34  cases  and 
absent  in  one.  Various  observers  took  the  temperature  of  the 
legs,  finding  in  some  cases  as  low  a  temperature  as  20.0°  C. 
In  29  cases  pallor  of  the  legs  was  present,  and  in  no  case 
was  it  stated  to  have  been  absent.  In  17  cases  mottling  was 
present,  no  statement  being  made  as  to  the  remainder. 

The  presence  of  gangrene  was  noted  in  one  or  both  legs  in 
31  cases,  was  stated  to  have  been  absent  in  13,  and  was  not 
recorded  in  6.  Out  of  the  31  cases  it  was  present  in  both 
legs  in  26  and  in  only  one  in  5.  When  present  in  both  legs 
usually  the  extent  was  different  in  each.  No  attempt  was 
made  to  record  the  exact  variation  in  this  regard.  Occa- 
sionally the  gangrene  progressed  above  the  legs  before  death 
occurred.  For  example,  in  Price's  case  by  the  eleventh  day 
the  right  leg  was  cold,  by  the  13th  mottling  was  present,  by  the 
15th  the  left  leg  was  afifected  in  the  same  way  and  later  the 
gangrene  spread  up  the  abdomen  to  the  umbilicus,  and  the  left 


OCCLUSION  OF  THE  ABDOMINAL  AORTA 


"5 


forearm  also  was  gangrenous,  probably  from  embolism  At 
the  autopsy  the  wall  of  the  bladder  was  found  to  be  black  and 
gangrenous  looking,  and  the  uterine  cavity  was  black.  In  an- 
other case  there  was  gangrene  up  to  the  gluteal  region. 

The  following  summary  is  drawn  from  the  few  cases  in 
which  statements  were  made  regarding  the  appearance  of 
definite  signs  of  gangrene  (the  final  outcome  of  anemia)  in 
its  relation  to  the  onset  of  the  symptoms;  the  time  from  the 
onset  of  the  symptoms  to  death,  and  the  time  from  the  onset 
of  the  gangrene  to  death : 

Time  Elapsing  Between 
A.     Onset    of   Symptoms    and        B.     Onset    of    Gangrene 
(i)   Gangrene;       (2)  Death. 


I 

2T,   days. 

27  da) 

2. 

16 

48   " 

3- 

14 

30  " 

4- 

13 

15   " 

5- 

8 

39  " 

6. 

7 

II   " 

7- 

6 

19  " 

8. 

6 

46  « 

9- 

5 

22  " 

10. 

5 

9  " 

II. 

3 

43  " 

12, 

^1/2 

1/2" 

13- 

^1/2 

1/2" 

14. 

^1/2 

1/2" 

and  Death 

4 

days. 

32 

16 

2 

31 

4 

13 

40 

17 

4 

40 

These  figures  are  too  few  to  average,  but  it  will  be  noted 
that  in  10  out  of  14  cases  gangrene  developed  in  8  days  or 
less. 

Observations  of  the  pulsation  of  the  femoral  arteries 
showed  that  in  32  out  of  33  cases  pulsation  was  absent.     In 

'  These  figures  are  included  because  the  gangrene  developed  in  this  length  of 
time  or  less.  In  Case  12  it  was  stated  that  "both  legs  were  black  for  some  hours 
before  the  fatal  result"  so  that  apparently  well-marked  gangrene  developed  in  a 
very  short  time  after  the  onset. 


Il6  SURGICAL  ANEMIA  AND  RESUSCITATION 

the  case  which  was  the  apparent  exception  the  pulsation 
was  very  feeble,  and  the  patient  died  in  12  hours.  As 
in  other  cases  in  which  there  was  a  feeble  pulsation  at  first, 
which  soon  ceased,  it  is  probable  that  in  this  case  the  pulsation 
would  have  ceased  altogether  if  the  patient  had  lived  longer. 
In  II  cases  in  which  a  statement  was  made  the  dorsalis  pedis 
arteries  were  pulseless. 

In  regard  to  edema  of  the  legs,  it  was  said  to  have  been 
present  in  5  cases,  absent  in  2,  while  no  statement  was  made 
in  43.  The  knee-jerks  were  said  to  have  been  absent  in  6 
cases,  and  in  no  case  present,  no  statement  regarding  knee-jerk 
being  made  in  the  remainder  of  the  cases  studied.  In  2  cases 
the  cremasteric  reflex  was  said  to  have  been  absent. 

As  to  the  third  general  cardinal  symptom  of  collapse,  a 
great  variation  in  manifestations  was  found.  Usually  there 
were  extreme  prostration,  with  or  without  fever,  dyspnea, 
rapid,  weak,  irregular  pulse,  with  finally  delirium,  coma,  and 
death.  In  10  cases  statements  regarding  incontinence  of  urine 
and  feces  were  positive  in  9  and  negative  in  i.  It  is  unfor- 
tunate that  more  observations  were  not  made  on  this  point. 
Quite  often  serious  bedsores  developed.  In  6  cases  sweating 
was  present,  this  being  not  only  characteristic  of  profound 
collapse,  but  probably  indicative  also  of  the  temporarily 
greatly  increased  blood-pressure  in  the  upper  part  of  the  body. 
In  8  cases  mention  is  made  of  the  presence  of  red  blood  cor- 
puscles in  the  urine,  and  in  5  more  of  their  absence.  On  ac- 
count of  the  often-associated  cardiovascular  conditions,  the 
albumin  also  present  in  the  urine  was  of  little  consequence. 
Hiccough  was  present  in  3  cases,  but  little  significance  can  be 
attached  to  it.  With  the  presence  of  gangrene,  particularly 
when  moist,  the  terminal  symptoms  of  profound  toxemia  or 
sapremia  were  characteristic  of  gangrene  of  the  extremities 
due  to  any  cause. 


OCCLUSION  OF  THE  ABDOMINAL  AORTA  117 

In  regard  to  the  diagnosis  of  obstruction  of  the  abdominal 
aorta  little  need  be  said.  A  typical  case  should  be  recognized 
quickly,  and  a  large  majority  of  cases  will  be  of  embolic  origin. 
As  Blumer  states  in  Osier's  "Modern  Medicine,"  some  of  the 
more  chronic  cases  at  some  stages  might  suggest  Raynaud's 
disease,  but  careful  consideration  of  the  symptoms  should 
enable  the  latter  to  be  ruled  out.  The  same  may  be  said  of 
acute  myelitis.  Cases  of  asymmetrical  gangrene  can  usually 
be  traced  so  readily  to  their  individual  etiologic  origin,  and 
gangrene  of  one  extremity  so  rarely  occurs  in  obstruction  of 
the  aorta,  that  here  again  it  would  be  unusual  to  meet  with 
difficulties  in  diagnosis. 

The  prognosis  in  cases  of  obstruction  of  the  abdominal 
aorta  is  practically  hopeless.  Primarily  it  rests  on  the  estab- 
lishment of  collateral  circulation.  There  have  been  enough 
cases  to  indicate  that  a  collateral  circulation  consistent  with 
life  can  be  established.  Keen  had  a  remarkable  case  in  which 
the  patient  lived  for  48  days  after  ligation.  No  gangrene  de- 
veloped, and  at  the  autopsy  a  large  amount  of  blood  was  found 
in  the  abdomen,  the  ligature  around  the  aorta  having  cut 
through.  Before  1850  Monteiro  had  a  case  in  which  the 
patient  survived  ten  days  and  twenty  hours,  death  in  this  case 
also  occurring  from  the  cutting  through  of  the  ligature.  A 
patient  of  Tillaux's  survived  39  days,  but  it  was  found  that 
the  aorta  was  not  completely  occluded. 

While  the  following  remarkable  case  of  Sir  William  Gull's 
did  not  come  to  autopsy  the  lack  of  doubt  as  to  the  diagnosis 
of  obstruction  makes  it  well  worth  recording  in  detail  in  the 
observer's  own  words : 

"J.  B.,  set.  34,  employed  as  a  shipwright  in  the  dockyard  at  Wool- 
wich. Habits  temperate.  Accustomed  to  take  part  in  carrying  heavy 
loads;  and,  being  over  six  feet  in  height,  the  greatest  share  of  the 
weight  often  falls  to  him.     At  the  beginning  of  March,  1855,  being 


Ii8  SURGICAL  ANEMIA  AND  RESUSCITATION 

then,  as  he  supposed,  in  good  health,  he  was  suddenly  seized  (author's 
itaUcs),  while  at  work  in  a  stooping  posture,  with  pain  round  the 
loins.  This  went  off  after  he  had  rested  a  few  minutes.  With  the 
pain  he  had  a  desire  to  go  to  stool,  but  without  eifect.  As  he  re- 
sumed his  work  the  pain  returned,  and  extended  down  the  legs,  with 
a  sense  of  numbness,  soon  followed  by  entire  paralysis,  both  of  sen- 
sation and  motion,  from  the  loins  downward.  The  sphincters  were 
paralyzed.  After  a  few  days  sensation  returned,  and  he  was  able  to 
take  a  few  steps  unsupported.  He  gradually  improved,  but  the  gait 
remained  unsteady,  and  the  use  of  the  legs  soon  brought  on  increased 
weakness  and  numbness.  For  these  paraplegic  symptoms  he  was  ad- 
mitted, under  my  care,  into  Guy's  Hospital,  in  June  of  the  same  year. 
On  examining  the  spine  no  tenderness  nor  irregularity  could  be  de- 
tected, but  on  auscultation  a  soft,  bellows  murmur  was  audible  down 
the  back,  but  most  distinctly  at  the  lower  angle  of  the  scapula,  on  the 
left  side.  There  was  no  pain  or  tenderness  at  the  part,  nor  any  pain 
in  the  course  of  the  intercostal  nerves.  Percussion  elicited  slight 
dulness  where  the  murmur  was  most  audible.  Anteriorly,  under  the 
ensiform  cartilage  and  lower  third  of  the  sternum,  there  was  a  pro- 
longed bellows  murmur,  not  heard  so  distinctly  upward  in  the  course 
of  the  aorta,  or  toward  the  left  axilla.  There  was  no  pulsation  in 
the  abdominal  aorta,  nor  in  the  arteries  of  the  lower  extremities. 
The  legs  were  cold,  the  muscles  wasted;  no  edema  nor  any  venous 
turgescence  in  them.  The  superior  epigastric  artery,  on  the  right 
side,  was  enlarged,  and  could  be  distinctly  seen  pulsating  for  two 
inches  of  its  length,  the  blood  running  from  above  downward.  From 
that  date  until  the  present  time  (August,  1857)  the  case  has  remained 
under  notice.  The  superficial  arteries  of  the  back  and  abdomen  have 
gradually  enlarged.  A  few  of  the  principal  branches  seen  by  the 
artist,  as  the  patient  sat  before  him,  are  shown  in  the  sketches 
*  *  *  These  give,  however,  but  a  feeble  idea  of  the  extent 
of  the  arterial  anastomosis  as  it  can  be  traced  by  the  finger  under 
the  integuments.  At  the  posterior  boundary  of  the  axilla,  on  either 
side,  the  small  arteries  are  so  numerous  as  to  form  a  soft  pulsating 
mass,  reminding  one  of  the  rich  arterial  plexuses  in  the  intercostal 
spaces  of  the  cetacea.  The  enlarged  arteries  on  the  back  emerge  at 
the  fourth  and  fifth  intercostal  spaces,  and  dip  again  at  the  ninth. 
The  anastomosis  is  much  more  extensive  on  the  back  and  sides  of 
the  trunk  than  on  the  abdominal  walls.  From  time  to  time  he  has 
slight  returns  of  weakness  and  numbness  in  the  legs.  No  pulsation  is 
yet  discoverable  in  the  aorta  or  femoral  arteries,  nor  in  a)iy  of  their 
branches  (author's  italics).     The  systolic  murmur  at  the  lower  third 


OCCLUSION  OF  THE  ABDOMINAL  AORTA 


119 


of  the  sternum  remains.  The  chief  part  of  the  murmur  now  heard  in 
the  back  is  apparently  referable  to  the  rush  of  blood  along  the  numer- 
ous subcutaneous  channels  of  anastomosis.  The  patient  has  regained 
power  to  walk  tolerably  well,  but  his  muscles  are  thin  and  his  gait 
languid.  Feet  cold  and  damp.  His  general  health  is  good,  and  he  is 
able  to  do  the  lighter  parts  of  his  work.  The  pulsation  of  the  arteries 
of  the  upper  extremities  is  full  and  throbbing,  and  the  heart's  impulse 
increased.     There  is  no  sign  of  venous  obstruction." 

The  typical  symptoms  of  obstruction  of  the  abdominal 
aorta  were  present  in  this  case,  and  that  the  obstruction  was 
complete  seems  probable  from  the  fact  that  no  pulsation  was 
discoverable  in  the  aorta  itself  or  in  the  femoral  arteries  or 
their  branches  after  as  long  a  period  as  two  years  and  four 
months,  the  later  history  being  unknown.  There  is  no  doubt 
but  that  the  collateral  circulation  was  sufficiently  established  to 
maintain  life.  Whether  it  was  a  case  of  embolism  or  of  throm- 
bosis is  of  little  consequence,  although  from  the  sudden  onset 
the  former  is  suggested,  the  source  being  probably  an  aneurysm. 

In  the  50  cases  used  in  the  author's  study  the  mortality 
was  100  per  cent.  As  a  general  rule,  it  may  be  stated  that  pa- 
tients with  thrombosis  survive  much  longer  than  those  with 
embolism.  It  should  be  remembered  in  connection  with  the 
former,  however,  that  the  onset  is  insidious,  and  that  symp- 
toms sufficiently  pronounced  to  suggest  the  diagnosis  may 
appear  and  persist  for  a  long  time  when  only  partial  obstruc- 
tion is  present.  The  duration  from  onset  to  death  in  all  the 
50  cases  was  as  follows : 


Duration  f 

■rom  Onset  to  Death 

Number 

of  Patients 

210 

days. 

I* 

180 

i' 

75 

I* 

60 

I* 

48 

2* 

46 

l" 

NOTE.- 

-See  footnotes  on 

following 

page. 

I20 


SURGICAL  ANEIMIA  AND  RESUSCITATION 


Duration  from  Onset   to  Death 
45     days. 
39      "' 
33      " 
30      " 
27      " 

22  " 
21  " 
19        " 

15         " 

11  " 

9      "    • 

7      " 
4      " 

3/2    " 

3      " 

2        " 

iy2 " 

iH  " 

I      /l2 

I  day. 

12  hours. 
10        " 

Not  stated. 


Number  of  Patients 


3 

I 

_5 

50 


^  Thrombosis. — One  leg  only  was  gangrenous.  ^  Thrombosis. — 
Both  legs  gangrenous,  one  after  the  other.  ^Embolism,  but  Avith  one 
leg  affected  temporarily  only.  *  The  case  was  probably  one  of  pri- 
mary embolism,  with  complete  obstruction,  followed  by  thrombosis. 
Gangrene  was  present,  but  whether  both  legs  were  affected  was  not 
stated.  °  One  of  these  was  a  ligation  case,  with  establishment  of  the 
collateral  circulation  (Keen),  the  other  an  unusual  case  as  regards 
duration  with  both  legs  amputated  for  gangrene.  *  One  leg  only 
gangrenous.  ''  Embolism,  both  legs.  ^  Embolism,  both  legs  gangren- 
ous. Was  very  extensive,  gluteal  region  affected.  *  No  gangrene. 
Collateral  circulation  established.  Autopsy.  "  Embolism,  with  be- 
ginning gangrene  of  left  leg.  "  Embolism,  gangrene  did  not  begin 
until  twenty-third  day.  "Embolism.  "Two  of  the  cases  of  throm- 
bosis are  included  ainong  these  s  cases. 


OCCLUSION  OF  THE  ABDOMINAL  AORTA  I2I 

The  duration  from  onset  to  death  in  the  ligation  cases  only 
is  given  in  the  following  table: 


Author 

Duration 

from  Ligation  to  Death 

I.  Keen. 

48      days. 

2.  Morris  (ligation  for  27  hours). 

3         " 

3.  Watson. 

2H       " 

4.  South. 

2 

5.  Czerny. 

1%       " 

6.  Milton. 

I 

7.  Stokes. 

12      hours. 

8.  McGuire. 

12 

9.  Czerny. 

ID 

It  is  seen  from  the  above  table  that  death  usually  occurred 
soon  after  ligation.  The  operative  factors  would  doubtless 
greatly  augment  the  seriousness  of  the  procedure,  to  say  noth- 
ing of  the  underlying  conditions  for  which  the  ligation  was 
performed. 

The  only  possible  treatment  for  obstruction  of  the  abdom- 
inal aorta  must  be  through  surgical  intervention  immediately 
after  the  sudden  onset  of  definite  symptoms,  but  aside  from 
general  considerations,  the  technical  details  furnish  insuper- 
able obstacles  in  many  ways.  In  the  absence  of  harmful  mul- 
tiple emboli  it  might  be  conceived  that  the  operation  could  be 
carried  through  by  temporary  closure  of  the  aorta  just  below 
the  level  of  the  inferior  mesenteric  artery,  by  then  opening  the 
vessel  and  gently  withdrawing  the  embolus.  If  the  embolus 
were  found  to  extend  up  above  the  level  of  temporary  ligation 
the  clamp  could  be  temporarily  partially  released  in  the  hope 
that  the  blood  stream  would  wash  it  down,  care  being  taken  to 
prevent  it  from  getting  below  the  bifurcation.  This  would  be 
possible  only  under  absolute  control  of  the  hemostasis,  and 
with  a  much  calcified  aorta  such  control  would  probably  be 


122  SURGICAL  ANEMIA  AND  RESUSCITATION 

impossible.  On  the  other  hand,  if  it  were  doubtful  whether  all 
clot  below  the  bifurcation  had  been  removed  there  might  be  a 
possibility  of  removing  it  all,  or  most  of  it,  by  introducing  a 
tube  of  suitable  size  into  the  lower  part  of  the  aorta  and  as- 
pirating vigorously  with  or  without  the  preliminary  introduc- 
tion of  a  small  stream  of  normal  saline  solution  to  assist  in 
dislodging  the  clot.  An  ordinary  aspirating  set  with  a  glass 
tube  of  suitable  size  with  tapered  end,  could  be  easily  procured 
for  such  an  attempt.  After  removal  of  the  clot  one  of  the 
most  difficult  parts  of  the  technique  would  remain — sewing 
up  the  aorta  with  sufificient  accuracy  to  prevent  leakage,  and 
with  sufficient  strength  to  prevent  tearing  out  of  the  sutures. 
The  author  would  attempt  to  introduce  very  closely  placed  fine 
sutures,  according  to  Carrel's  method  of  closing  such  a  blood 
vessel,  and  would  then  reinforce  them  with  much  larger  su- 
tures not  passing  through  the  intima.  In  the  meantime  the 
blood-pressure  should  be  held  at  as  low  an  ebb  as  possible  by 
means  of  sodium  nitrite  in  maximum  dosage.  By  a  most 
happy  combination  of  fortunate  circumstances,  it  is  conceiv- 
able that  life  could  be  saved  by  this  method. 


CHAPTER  V 

ANEMIA    OF   VOLUNTARY    MUSCLES  I     CLINICAL    OBSERVATIONS. 

ANEMIA  OF  THE  LOWER  EXTREMITIES  IN  MAN  THROUGH 

LIGATION   OF  THE   MAIN   ARTERIAL  TRUNKS 

In  making  an  extensive  study  of  ligation  of  the  main  arte- 
rial trunks  of  the  lower  extremities  it  was  rather  surprising  to 
note  how  little  of  consequence  was  to  be  found  in  the  litera- 
ture of  the  subject  in  regard  to  the  changes  due  to  anemia 
which  fall  short  of  gangrene — for  example,  muscular  atrophy 
and  nerve  degenerations,  with  accompanying  disturbances  of 
locomotion  and  sensation.  Apparently  the  patients  either  had 
gangrene  or  entirely  recovered,  no  middle  ground  ever  being 
recorded.  This  may  be  interpreted  in  one  of  two  ways  :  either 
the  observations  were  not  made  with  sufficient  care,  or  else 
such  changes  did  not  occur.  In  certain  cases  in  which  recov- 
ery took  place  the  usual  temporary  coldness  and  pallor  of  the 
extremity  were  reported,  but  no  more  disturbance  was  seen 
than  might  commonly  be  found.  Opinion,  therefore,  must 
incline  toward  the  view  that  final  functional  restoration  was 
complete.  Depriving  parenchymatous  organs,  for  instance  the 
thyroid  gland,  of  part  of  their  blood  supply  leads  to  permanent 
diminution  in  the  functional  capacity  without  gangrene,  but 
with  increase  in  the  connective  tissue  elements,  but  no  similar 
condition  seems  to  occur  when  the  same  thing  is  done  to  the 
extremities. 

Many  factors  may  complicate  the  problem  of  ligation 
of  the  iliac  or  femoral  arteries  besides  that  of  the  estab- 
lishment of  collateral  circulation.       The  age  of  the  patient 

123 


124  SURGICAL  ANEMIA  AND  RESUSCITATION 

may  have  an  important  influence,  the  generally  lowered  resis- 
tance to  shock  and  infection  which  accompanies  arterio- 
sclerosis,  or  the  relative  anemia  of  lowered  blood-pressure 
from  different  causes,  may  predispose  to  gangrene.  Then 
again  an  extremely  important  part  is  played  by  the  condition 
for  which  the  ligation  is  done.  In  a  majority  of  all  cases 
hemorrhage  is  present  and  not  only  endangers  life  directly, 
but  indirectly,  through  diminishing  the  nutrition  of  the  tissues 
and  thereby  predisposing  them  to  gangrene.  Moreover,  with 
incised,  punctured,  or  gunshot  wounds,  and  with  compound 
fracture  there  is  usually  infection  of  varying  degree.  Among 
the  non-traumatic  complications  aneurysms,  neoplasms,  cari- 
ous bone,  and  elephantiasis  may  be  mentioned.  The  structure- 
obscuring  swelling  of  infection  or  of  traumatic  aneurysm  may 
add  greatly  to  the  difficulty  of  locating  the  arteries  to  be 
ligated,  and  cases  are  on  record  in  which  religation  has  been 
necessary,  still  more  of  the  blood  supply  being  thus  cut  off 
since  the  proper  vessel  could  not  be  distinguished.  Abnor- 
malities of  the  vessels  themselves  may  lead  to  ineffectual  liga- 
tion, to  unexpected  hemorrhage,  or  to  the  shutting  off  of  valu- 
able collateral  trunks.  Finally,  unless  both  ends  of  a  severed 
artery  can  be  secured,  tying  the  central  end  alone  may  give 
temporary  cessation  of  hemorrhage,  but  subsequent  serious 
hemorrhage  may  occur  through  the  collateral  vessels  with  the 
sacrifice  of  still  more  of  the  blood  supply  if  the  peripheral  end 
cannot  be  reached. 

Factors  Efitering  into  Ligation  of  the  Femoral  Artery  and  Its 

Branches 
1.    Age  of  the  Patient. 

A.  Arteriosclerosis. 

B.  Weakened  heart  action. 

a.  Slowing  of  the  blood  stream. 

b.  Relative  anemia. 

C.  General  lowered  resistance  to  shock,  infection,  etc. 


LIGATION  OF  THE  COMMON  ILIAC  ARTERY  125 

2.  Nature  of  the  Reason  for  Ligating. 

A.  Traumatism. 

a.  Incised  wounds. 

b.  Punctured  wounds. 

c.  Gunshot  wounds. 

d.  Fractures. 

( 1 )  Compound. 

(2)  Simple. 

B.  Non-traumatic  cases. 

a.  Aneurysm. 

b.  Neoplasm. 

c.  Removal  of  carious  bone. 

d.  Elephantiasis. 

3.  Infection  (One  of  the  Most  Important  Complicating  Factors). 

A.  Difficulty  in  ascertaining  landmarks  on  account  of  swelling, 

pus-formation. 

B.  Difificulty  in  tying  off  vessels. 

C.  Necrosis  of  vessel  wall  after  ligation,  necessitating  reli- 
gation. 

4.  Abnormal  Variations  in  the  Arteries. 

From  the  foregoing  alone  it  is  easily  seen  how  difficult  it 
is  to  predict  what  will  happen  when  a  given  artery  is  ligated. 
In  the  following  pages,  in  using  cases  from  different  sources 
in  the  literature,  it  has  seemed  best  to  confine  the  attention  al- 
most wholly  to  the  frequency  of  occurrence  of  gangrene  and 
the  time  of  its  appearance  in  relation  to  the  operation.  Only 
cases  later  than  1850  have  been  used. 

I.    LIGATION   OF  THE  COMMON  ILIAC  ARTERY 

Dreist  has  published  the  most  complete  compilation  of 
cases  of  ligation  of  the  common  iliac  artery,  his  series 
amounting  to  78  in  all.  Among  these  cases  there  were 
13  in  which  gangrene  developed.  Gillette  adds  two  cases  to 
those  gathered  by  Dreist,  one  from  the  British  Medical  Jour- 
nal, and  the  other  a  case  of  his  own.     In  the  80  cases,  as 


126  SURGICAL  ANEMIA  AND  RESUSCITATION 

analyzed  by  Gillette,  gangrene  occurred  altogether  14  times, 
or  in  17.5  per  cent.  Before  the  antiseptic  era  the  mortality 
was  yy  per  cent.  Since  1880  the  mortality  has  fallen  to  33 
per  cent.  The  occurrence  of  gangrene,  therefore,  is  not  neces- 
sarily an  index  of  the  death  rate.  Fortunately,  the  necessity 
for  performing  this  dangerous  operation  does  not  often  arise. 

n.    LIGATION   OF  THE  EXTERNAL  ILIAC  ARTERY 

One  hundred  and  thirty-five  cases  of  ligation  of  the  ex- 
ternal iliac  artery  were  tabulated  at  random  from  the  litera- 
ture. Among  these  gangrene  was  stated  to  have  occurred  16 
times,  or  in  11  per  cent.  In  4  of  the  16  cases  the  external 
iliac  was  not  the  only  artery  ligated,  so  that  there  was  addi- 
tional interference  with  the  blood  supply.  Gangrene  was  asso- 
ciated with  ligation  for  spontaneous  aneurysm  6  times,  for 
gunshot  injuries  5  times,  for  traumatic  aneurysm  3  times,  and 
in  the  remaining  2  cases  the  associated  condition  was  not 
stated. 

In  only  a  few  cases  were  definite  statements  made  as  to  the 
duration  of  time  between  the  ligation  and  the  appearance  of 
gangrene.  In  the  cases  in  which  the  external  iliac  artery  alone 
was  ligated  gangrene  appeared  as  follows : 

In  case  i — after  25  days. 

In  case  2 — after  11  days. 

In  case  3 — after     3  days. 

In  case  4 — after     i  day. 

In  the  4  cases  in  which  more  than  the  external  iliac  was 
ligated  gangrene  appeared  in  all  four  on  the  third  day  after 
ligation.  In  3  other  cases  in  which  gangrene  was  stated  to 
have  occurred,  but  in  which  no  statement  was  made  as  to  the 
exact  time  of  its  appearance,  death  occurred  on  the  7th,  5th, 


LIGATION  OF  THE  COMMON  FEMORAL  ARTERY  1 27 

and  4th  days  respectively.  In  these  cases,  therefore,  gangrene 
had  developed  in  less  than  a  week. 

Death  terminated  all  but  one  of  the  16  cases  with  gangrene. 
The  patient  that  survived  had  his  leg  amputated.  While  gan- 
grene must  have  played  a  serious  part  among  the  lethal  ele- 
ments, too  much  stress  should  not  be  laid  on  it  in  the  presence 
of  hemorrhage,  sepsis,  and  shock. 

As  showing  the  possibilities  of  ligation  of  this  vessel  the 
following  remarkable  case  is  of  interest : 

Moschowitz  reports  what  he  considers  to  be  the  only  case 
on  record  in  which  simultaneous  ligation  of  both  external  iliac 
arteries  has  ever  even  been  attempted.  The  double  ligation  was 
done  for  hemorrhage  following  bilateral  ureterolithotomy  in 
a  man  36  years  of  age.  All  pulsation  ceased  below  the  points 
of  ligation,  both  lower  extremities  becoming  blanched.  On 
the  evening  of  the  same  day  "the  toes  were  warm,  of  a  deli- 
cate pink  hue,  and  capable  of  slight  active  motion.  On  the 
following  day  slight  femoral  pulsation  was  to  be  felt,  and  on 
the  third  day  an  occasional  flutter  was  noted  in  the  dorsalis 
pedis  artery."  In  spite  of  the  critical  nature  of  all  of  the 
surgical  procedures  and  the  formidable  loss  of  blood,  complete 
recovery  took  place. 

m.    LIGATION   OF  THE   COMMON  FEMORAL  ARTERY 

One  hundred  and  fifty  cases  of  ligation  of  the  common 
femoral  artery  were  tabulated.  In  regard  to  etiology,  the 
ratio  of  males  to  females  was  as  7  to  2,  doubtless  because 
women  are  more  protected  than  men  from  traumatic  injury; 
the  youngest  patient  was  10  years  old  and  the  oldest  78  years; 
grouping  the  cases  by  decades  clearly  showed  that  most  cases 
occurred  in  the  most  active  periods  of  life.  Traumatism  and 
resulting  hemorrhage  were  in  almost  all  cases  the  direct 
causative  factors  necessitating  ligation. 


128  SURGICAL  ANEMIA  AND  RESUSCITATION 

In  29  cases,  practically  20  per  cent,  gangrene  of  the  leg  of 
greater  or  less  extent  was  present.  In  11  out  of  the  150 
cases  the  continuity  of  the  femoral  vein  was  interrupted  either 
by  traumatism  or  by  simultaneous  ligation  with  the  artery.  In 
only  2  of  these  1 1  cases  did  gangrene  develop  definitely,  while 
in  a  third  it  showed  signs  of  developing,  but  recovery  took 
place.  Therefore,  as  would  be  expected  from  the  presence  of 
the  free  venous  anastomoses  of  the  leg,  it  is  not  apparent  that 
ligation  of  the  femoral  vein  in  addition  to  ligation  of  the  fem- 
oral artery  makes  the  development  of  gangrene  more  im- 
minent. , 

Among  the  29  cases  in  which  gangrene  occurred  there 
were  25  of  traumatic  and  4  of  non-traumatic  origin.  Among 
the  former  the  associated  conditions  were :  gunshot  injury,  10 
times;  hemorrhage  after  operation  for  malignancy,  5  times; 
traumatic  aneurysm,  3  times;  fracture  of  femur,  i  time;  and 
cases  with  the  nature  of  the  traumatism  not  stated,  6  times. 
Among  the  4  non-traumatic  cases  3  were  associated  with  spon- 
taneous aneurysm,  and  i  with  elephantiasis. 

When  it  comes  to  statements  of  the  exact  time  of  appear- 
ance of  gangrene  after  ligation  the  figures,  as  a  whole,  are 
disappointing.  Some  assistance  is  obtained  from  the  fact  that 
gangrene  was  said  to  have  been  present  and  that  death  oc- 
curred at  such  and  such  a  time  after  ligation,  so  that  we  know 
at  least  the  time  before  which  gangrene  must  have  occurred. 
The  definite  and  the  inclusive  figures  are  shown  in  the  follow- 
ing tables : 

Definite  Statements 


Case  No. 

Tmie  of  Appearance  of  Gangrene 

I. 
2. 
3- 

yy  days. 
14  days. 
12  days. 

ie  No. 

Time  of  Appearance  of  Gangrene 

4. 

6  days. 

5- 

5  days. 

6. 

2  days. 

7- 

2  days. 

8. 

2  days. 

Case  No. 
I 

2 

3 

4 

5 
6, 

7 
8 

9 
10 
II 


Inclusive  Statements 

Time  Before  Which  Gangrene  Occurred 
25  days,  death. 
19  days,  death. 
17  days,  recovery  after  amputation. 

7  days,  death. 

4  days,  death. 

4  days,  death. 

4  days,  death. 

3  days,  death. 

3  days,  death. 

3  days,  death. 

2  days,  death. 


From  both  of  the  foregoing  tables  it  is  seen  readily  that 
gangrene  occurred  in  13  out  of  19  cases  in  a  week  or  less,  the 
average  being  3.6  days.  Between  2  and  3  days  would  prob- 
ably be  a  more  correct  figure  when  the  inexactness  of  the 
second  table  is  considered.  In  the  77-day  case  in  Table  I  the 
question  arises  as  to  how  much  part  was  played  by  other 
changes  besides  the  ligation,  as  the  patient  was  64  years  old 
and  had  a  spontaneous  aneurysm. 

The  mortality  among  the  29  cases  in  which  gangrene  oc- 
curred was  very  high,  all  but  2  of  the  patients  dying.  In  the 
2  recovery  cases  amputation  was  done.     While  a  few  of  the 


I30  SURGICAL  ANEMIA  AND  RESUSCITATION 

fatal  cases  were  complicated  by  amputation,  it  is  probable  that 
this  hastened  the  termination  but  little.  In  many  of  the  cases 
the  loss  of  blood  was  great. 

IV.    LIGATION  OF  THE  EXTERNAL  FEMORAL  ARTERY 

In  the  289  cases  of  ligation  of  the  external  femoral  artery 
studied  by  the  author  due  acknowledgment  is  made  to  Rabe 
for  many  cases  borrowed  from  his  compilation. 

Among  the  289  cases  there  were  44  in  which  gangrene 
occurred,  or  practically  15  per  cent.  Of  the  44  cases  25  were 
of  traumatic  origin.  Among  these  the  associated  conditions 
were:  gunshot  injury,  8;  post-operative  hemorrhage,  6;  trau- 
matic aneurysm,  4;  fractures  (i  compound,  i  nature  not 
stated),  2;  and  cases  in  which  the  nature  of  the  traumatism 
was  not  stated,  5.  On  comparing  this  list  with  the  one  given 
under  ligation  of  the  common  femoral  artery  it  will  be  noted 
that  the  sequence  is  identical  from  gunshot  injury,  as  the  most 
frequent  associated  traumatic  condition,  to  fractures,  as  the 
least  frequent.  Among  the  19  non-traumatic  cases  the  associ- 
ated condition  was  spontaneous  aneurysm,  16 ;  false  aneurysm, 
2;  and  elephantiasis,  i. 

In  regard  to  the  duration  of  time  between  ligation  and  the 
appearance  of  gangrene  it  must  again  be  said  that  the  figures 
are  disappointing,  although  the  time  is  given  more  often  than 
in  other  groups  of  cases.  As  before,  the  definite  and  the  in- 
clusive figures  are  shown  in  the  following  tables : 

Definite  Statements 


Case  No. 

Time  of  Appearance  of  Gangrene 

I. 
2. 
3- 

21  days, 
21  days. 
18  days. 

LIGATION  OF  THE  EXTERNAL  FEMORAL  ARTERY  131 


Case  No. 

Time 

of  Appearance  of  Gangrene 

4. 

13  days. 

5. 

9  days. 

6. 

5  days. 

7- 

3  days. 

8. 

3  days. 

9. 

3  days. 

10. 

3  days. 

II. 

2  days. 

12. 

2  days. 

Inclusive  Statements 


Case  No. 

Tim^  Before  Which  Gangrene  Occurred 

I. 

20  days,  death. 

2. 

20  days,  death. 

3- 

19  days,  death. 

4- 

14  days,  death. 

5. 

II  days,  death. 

6. 

II  days,  death. 

7- 

9  days,  death. 

8. 

8  days,  death. 

9- 

I  day,  death. 

It  is  seen  from  both  of  the  foregoing-  tables  that  in  8 
out  of  21  cases  gangrene  occurred  in  a  week  or  less,  the  aver- 
age time  being  2.7  days.  Here,  too,  the  relative  indefiniteness 
of  the  second  table  makes  the  average  more  or  less  inaccurate ; 
at  best  it  is  but  approximate. 

After  ligation  of  the  external  femoral,  amputation  played 
a  greater  part  in  reducing  the  mortality  than  after  ligation  of 
the  common  femoral.  In  all,  there  were  30  deaths  and  14 
recoveries.     In  10  of  the  fatal  cases  the  statement  was  made 


132  SURGICAL  ANEMIA  AND  RESUSCITATION 

that  amputation  was  performed,  while  in  the  remaining  20 
fatal  cases  no  statement  is  made  to  the  contrary.  In  13  of 
the  14  recoveries  it  was  stated  that  amputation  was  performed, 
while  in  the  14th  case,  in  which  gangrene  of  the  toes  was 
present,  no  statement  regarding  amputation  was  made. 

V.     GENERAL  RECAPITULATION 

From  these  studies  the  following  table  has  been  con- 
structed : 

•  Number  Percentage 

Vessel  Ligated                 of  Cases  with  Gangrene 

Common  iliac  artery 80   (Dreist,  Gillette)      17.3 

External  iliac  artery 135  11 

Common  femoral  artery..    150  20 

External  femoral  artery  .  .    289  15 

Bearing  in  mind  the  limitations  of  tlie  method  followed  in 
compiling  these  statistics  it  is  seen  that  the  occurrence  of  gan- 
grene does  not  really  depend  in  any  great  degree  upon  the  ves- 
sel ligated.  There  is  little  doubt  that  cases  operated  on  within 
the  last  decade  would  show  a  smaller  percentage  with  gan- 
grene, but  even  at  the  present  time  (through  the  very  nature  of 
the  conditions  for  which  ligation  has  to  be  done)  certain  dan- 
gers have  not  been  eliminated  and  cannot  be  eliminated.  The 
great  hope  of  to-day  lies  not  in  the  ability  to  prevent  the  oc- 
currence of  gangrene,  but  in  its  earlier  recognition,  in  earlier 
amputation,  in  a  better  handling  of  the  technical  part  of  ampu- 
tation, and  in  a  greater  understanding  of  the  problem  as  a 
whole. 


CHAPTER  VI 

ANEMIA    OF    VOLUNTARY    MUSCLES  :     CLINICAL    OBSERVATIONS. 
ISCHEMIC    PARALYSIS 

The  comparative  rarity  of  ischemic  paralysis  and  of  the 
paralysis  of  the  legs  following  embolism  of  the  abdominal 
aorta  necessitates  drawing  on  the  literature  of  both  of  these 
subjects  for  adequate  material. 

The  condition  known  as  ischemic  paralysis,  or  more  com- 
monly as  Volkmann's,  or  the  Volkmann-Leser  contracture,  is 
both  practically  and  theoretically  of  considerable  interest  from 
the  standpoint  of  surgical  anemia.  That  there  is  practically 
unanimity  of  opinion  that  anemia  is  the  primary  cause  of 
ischemic  paralysis  is  apparent  from  reading  the  various  ac- 
counts in  the  literature  of  the  subject,  but  it  is  equally  ap- 
parent that  there  is  considerable  difference  of  opinion  as  to 
whether  secondary  causes  should  be  sought  in  case  of  injury 
to  muscle  or  to  nerve  elements.  It  is  impossible  to  say  how 
much  weight  should  be  assigned  to  each  etiologic  factor,  but 
in  the  following  carefully  selected  cases  it  is  shown  that  cer- 
tain individual  factors,  which  may  or  may  not  be  combined 
in  any  given  case,  may  have  great  influence  in  causing  the 
paralysis. 

I.     Case  in  Which  Pressure  on  the  Muscles  Apparently  Played 
an  Important  Part 

In  this  case,  reported  by  H.  L.  Barnard,  the  patient  was  3 
years  old,  and  had  had  both  bones  of  the  forearm  broken. 

133 


134  SURGICAL  ANEMIA  AND  RESUSCITATION 

In  the  previous  treatment  of  the  case  anterior  and  posterior 
splints  had  been  applied  for  an  unstated  length  of  time.  The 
fact  that  sores  were  found  on  the  forearm  when  the  splints 
were  adjusted  three  weeks  after  the  accident  would  tend  to 
show  that  undue  pressure  was  used.  No  note  was  made  as  to 
whether  the  patient  could  or  could  not  move  her  fingers  at  this 
time,  but  contracture  began  about  one  month  after  the  acci- 
dent. A  typical  case  developed,  which  was  improved  by- 
operation  six  months  after  the  injury,  tendon  lengthening 
being  done.  The  muscles  exposed  were  "pale,  firm,  fibrous, 
and  dry  and  very  unlike  the  normal  succulent  vascular  mus- 
cles of  children,"  and,  as  no  mention  is  made  of  particular 
involvement  of  nerve  trunks  by  fibrous  contractions,  it  is  to  be 
presumed  that  such  involvement  was  absent  and  that  the 
pressure  on  the  muscles,  and  hence  anemia,  was  the  essential 
causative  factor. 

Many  other  cases  of  this  sort  are  reported  in  which  undue 
pressure  on  the  muscles  seemed  pretty  clearly  to  play  a  role  in 
the  cause  of  the  physical  changes.  It  seems  probable,  how- 
ever, in  certain  of  these  cases,  particularly  in  the  older  pa- 
tients, that  tight  splints  or  other  restraining  apparatus  were 
blamed  unjustly.  This  point  will  be  considered  more  fully 
under  cases  illustrating  the  effects  produced  by  the  injury  of 
nerve  trunks. 

The  consideration  of  the  preceding  typical  case  at  once 
gives  rise  to  the  question  as  to  whether  or  not  anemia  alone 
can  cause  muscular  contracture.  It  is  a  well-known  fact  that 
ligation  of  a  main  artery  of  a  limb  causes  either  gangrene  or 
recovery  with  restoration  of  function,  and  usually  the  latter. 
As  has  been  said  elsewhere  in  these  pages,  search  through  the 
literature  gives  little  or  no  evidence  of  any  conditions  between 
the  two  extremes,  apart  from  the  class  of  cases  now  under 
consideration.    If  the  case  reports  of  ligation  fail  to  show  the 


ISCHEMIC  PARALYSIS  13  S 

occurrence  of  contracture  in  any  cases  in  which  pressure,  at 
least  through  bandaging,  may  not  have  been  causative,  it  is 
necessary  to  look  elsewhere  for  evidence.  Fortunately  such 
evidence  seems  to  be  present  in  very  exceptional  cases,  in 
which  embolism  was  followed  by  more  or  less  muscular  con- 
tracture. That  these  cases  are  very  exceptional^  is  shown 
by  the  fact  that  many  cases  of  embolism  occur  in  which,  as  in 
the  cases  of  ligation,  there  seems  to  be  no  middle  ground — 
either  restoration  of  function  or  gangrene  occurs.  Here 
again,  however,  lack  of  accurately  detailed  observation  may  be 
at  fault.  Experimental  work  by  Lapinsky  on  rabbits  in  which 
he  ligated  arteries  resulted  only  in  flaccid  paralysis  without 
contractures. 

2.    Case  in  Which  Embolism  of  the  Brachial  Artery  Was  the 
Only  Etiologic  Factor 

This  case  of  Langer's  concerned  a  woman,  50  years  of  age, 
who  had  mitral  stenosis  and  slight  aortic  insufficiency,  and 
who  had  had  a  right-sided  hemiplegia  three  years  previously. 
She  had  entered  the  hospital  for  fever  and  cough  which  she 
had  had  for  two  weeks.  On  the  second  day  after  being  ad- 
mitted, and  immediately  after  taking  a  warm  bath,  paresthesia 
of  her  left  forearm  occurred  suddenly,  followed  very  shortly 
by  paralysis,  completely  flaccid  in  character,  frigor,  and  in- 
creasing cyanosis.  After  seven  hours,  flexion  of  the  hand 
.  and  finger  joints  was  noticed,  which  had  increased  after  five 
hours  more,  with  the  development  of  flexion  at  the  elbow 
joint.  This  muscular  rigidity,  similar  to  rigor  mortis,  dis- 
appeared in  the  course  of  the  next  few  hours,  and  it  was  only 
in  the  following  days  that  permanent  flexion  returned  again 

^  Desplats  and  Baillet  (Paralysie  et  nevrite  d'origine  ischemique,  ^rc/t. 
des  mal.  du  coeur,  igii,  IV,  481-544)  have  recently  reported  a  number  o± 
cases  of  this  kind. 


136  SURGICAL  ANEMIA  AND  RESUSCITATION 

in  consequence  of  reactive  changes  in  the  muscles.  These 
reactive  processes  could  be  recognized  clinically  by  hard  swell- 
ing, spontaneous  pain,  and  sensitiveness  to  pressure,  subse- 
quent atrophy,  shrinking  of  the  muscles,  and  permanent  con- 
tracture. No  splints  or  other  restraining  apparatus  causing 
pressure  were  used.  The  muscles  of  the  upper  arm  were  much 
less  affected  than  were  those  of  the  forearm  and  hand.  About 
two  and  one-half  months  after  the  onset  the  muscles  of  the 
forearm  were  found  to  be  diminished  in  volume,  and  felt 
thickened  and  tendonlike.  In  the  elbow  joint  there  was  slight 
flexion,  while  the  hand  was  bent  at  almost  right  angles  to 
the  arm,  and  a  little  toward  the  ulnar  side.  The  fingers  were 
slightly  extended  at  the  metacarpophalangeal  joint.  The 
thumb  was  pulled  over  into  the  palm.  The  balls  of  the  thumb 
and  little  finger  were  hard  and  considerably  reduced  in  size. 
The  skin  of  the  forearm  was  normal,  that  of  the  hand  thinned, 
and  that  of  the  fingers  shiny.  On  the  palm  of  the  hand,  the 
ball  of  the  thumb,  and  the  dorsal  surface  of  the  thumb  were 
numerous  tender  cicatrices.  On  the  thumb  and  middle  finger 
the  nails  had  disappeared,  on  the  small  and  index  fingers  rudi- 
ments of  the  nails  were  present,  while  the  nail  of  the  ring  fin- 
ger was  better  preserved.  Active  movements  were  very  much 
restricted.  Sensory  disturbance  was  marked.  The  previously 
present  edema  had  disappeared.  A  month  and  a  half  later 
there  was  some  improvement  in  the  sensory  disturbance,  but 
otherwise  the  condition  was  essentially  the  same. 

Langer  considers  that  the  above  case  shows  clearly  that 
muscular  contracture  may  follow  anemia  alone,  and  in  a  com- 
paratively short  time.  As  would  be  expected,  there  was  a 
preliminary  stage  of  contraction,  probably  functional  in  char- 
acter, followed  by  a  final  stage  in  which  permanent  organic 
changes  occurred.  In  the  preliminary  stage  the  contraction  of 
course  could  not  be  attributed  to  traumatic  injury  of  nerve 


ISCHEMIC  PARALYSIS  137 

trunks  or  of  individual  fibers.  On  the  other  hand,  the  anemia 
was  not  complete  or  the  ultimate  destruction  of  the  arm  would 
have  occurred,  so  that  irritative  or  other  changes  in  nerve 
endings  at  least  could  not  have  been  caused  by  complete  ane- 
mia. Therefore  it  would  seem  to  be  entirely  possible  that 
increased  local  pressure,  or  improperly  aerated  blood,  might 
cause  local  nerve  irritation,  and  hence  tonic  contracture — it 
not  being  necessary  to  have  the  nerve  irritation  go  as  far  as 
the  production  of  pain.  Later  there  was  time  for  "coagula- 
tion'' of  the  muscle  proteids  to  take  place  with  loss  of  fluid, 
and  resultant  contracture,  as  many,  if  not  all  animal  sub- 
stances containing  water  in  considerable  amounts  contract 
more  or  less  forcibly  on  losing  it,  as  gelatin,  for  example. 
Still  later  the  increase  in  the  connective  tissue  elements 
would  add  still  more  to  the  contraction,  and  eventually 
would  make  it  permanent  and  irreparable.  It  seems 
hardly  credible  that  anemia  could  cause  immediate  contrac- 
ture of  muscle  cells  without  interference  with  the  nerve 
supply.  Whether  the  above  explanation  holds  good  for 
the  very  rare  reported  cases  in  which  immediate  contrac- 
tion does  occur  can  be  determined  only  by  further  study, 
and  it  is  already  known  from  experimental  study  that  noth- 
ing more  than  flaccid  paralysis  has  been  observed  to  follow 
shutting  off  the  blood  supply — spastic  paralysis  has  not  been  ob- 
served. In  Langer's  case  it  is  very  evident  that  the  process  did 
not  stop  so  very  short  of  gangrene — why,  it  is  impossible  to 
say.  Why  contracture  should  apparently  happen  so  rarely 
may  be  due  to  the  possibility  that  in  certain  cases  of  embolism 
there  is  actually  present  a  preliminary  stage  of  contracture, 
which  may  be  slight  and  hence  not  noticed,  and  no  advanced 
stage,  either  on  account  of  complete  establishment  of  the  col- 
lateral circulation  on  the  one  hand,  or  of  gangrene  on  the 
other.    The  mere  fact  that  so  many  reported  cases  were  due. 


138  SURGICAL  ANEMIA  AND  RESUSCITATION 

or  were  thought  to  have  been  due,  to  previous  malpractice 
explains  partly  why  comparatively  little  is  known  about  the 
early  happenings. 

From  the  foregoing  cases  it  is  apparently  shown  that  gen- 
eralized pressure  on  the  muscles  may  lead  to  contracture,  and 
that  anemia  alone  may  do  the  same,  even  without  the  factor  of 
existence  of  gross  injury  of  the  nerve  trunks.  This  leads  to 
the  question  as  to  whether  peripheral  nerve  trunk  injury  alone 
can  lead  to  contracture.  To  elucidate  this  point  the  following 
illustrations  are  given. 

^A.     A  Case  in  Which  Marked  Muscular  Contracture  Fol- 
lowed Contusion  of  the  Leg;  Spontaneous  Recovery 

This  case  of  Barbier's  was  not  a  case  of  ischemic  paralysis. 
The  patient  was  a  male  with  an  alcoholic  history  who  was  run 
over  by  a  cab,  the  wheels  of  which  passed  over  both  his  legs, 
the  left  leg  in  particular  being  affected.  He  was  severely 
enough  injured  to  be  unable  to  return  home  unaided.  That 
night  he  noticed  that  his  left  foot  was  drawn  around  into  a 
position  which  did  not  change,  and  which,  on  his  entering  the 
hospital  the  next  day,  was  found  to  be  that  of  a  talipes  equino- 
varus.  Whether  this  position  came  on  immediately  after  the 
injury  could  not  be  ascertained.  The  extension  and  rotation 
of  the  foot  were  so  pronounced  that  the  astragalus  was  sub- 
luxated,  its  head  making  a  marked  projection  in  the  side  of 
the  foot.  The  plantar  arch  was  more  concave  than  normal, 
and  the  toes  were  strongly  extended  on  the  body  of  the  foot. 
The  malposition  was  not  absolutely  fixed — from  time  to  time 
the  foot  seemed  to  relax  spontaneously  or  after  excitation, 
returning  immediately  to  its  previous  position  by  a  series  of 
jerks.  Every  attempt  to  replace  the  foot  forcibly  resulted  only 
in  intolerable  pain.     When  the  patient  attempted  to  walk  the 


ISCHEMIC  PARALYSIS  139 

weight  of  the  body  rested  on  the  point  and  outer  side  of  the 
foot.  There  were  no  ecchymoses  or  traces  of  contusion  under 
the  skin  of  the  leg,  but  over  the  head  of  the  fibula  sharp  pain 
could  be  elicited  on  pressure,  and  there  was  a  zone  of  anes- 
thesia on  the  outer  aspect  of  the  leg.  No  evidence  of  fracture 
could  be  found.  Under  the  tightly  stretched  skin  over  the 
head  of  the  astragalus  the  presence  of  an  irritated  musculo- 
cutaneous nerve  was  proved.  The  least  contact  with  this  nerve 
caused  very  sharp  pain,  and  the  contracttire  seemed  to  he  more 
intense  after  each  application.  The  tibiotarsal  articulation 
also  seemed  to  be  tender.  It  was  then  found  that  electrical 
stimulation  of  the  peroneal  muscles  caused  the  foot  to  rotate 
back  practically  to  its  normal  position  but  did  not  reduce  the 
extension,  the  foot  immediately  returning  to  its  malposition 
on  stopping  the  stimulation.  Electrical  stimulation  with  either 
galvanic  or  faradic  current  applied  to  the  soleus  and  the  an- 
terior muscles  of  the  lower  leg  failed  to  cause  any  reaction. 
After  the  contracture  had  persisted  for  three  weeks  the  patient 
was  given  chloroform.  "A  peine  la  periode  de  resolution  com- 
mence-t-elle  que  le  pied,  jusqu'  a  lamaintenu  enrigiditepresque 
absolu,  retombe  inerte.  La  contracture  a  cesse  brusquement, 
d'un  seul  coup.  Les  mouvements  provoques  se  font  sans  rai- 
deur  aucune."  At  this  time  no  evidence  could  be  detected 
of  fracture  of  the  fibula.  Restraining  apparatus  was  tried 
twice — the  first  time  for  18  days,  and  the  second  for  about  a 
month — and  failed  to  relieve.  The  patient  left  the  hospital 
and  about  two  weeks  later  the  contracture  suddenly  disap- 
peared, two  and  one-half  months  after  the  accident. 

There  is  no  doubt  that  the  contracture  in  the  above  case 
was  due  to  functional  disturbance,  and  not  to  permanent  or- 
ganic changes  in  muscles  or  nerves,  because  of  (i)  its  disap- 
pearance immediately  under  general  anesthesia,  and  (2)  its 
eventual  disappearance. 


I40  SURGICAL  ANEMIA  AND  RESUSCITATION 

^B.     Case  of  Ischemic  Contracture  in  Which  Pressure  Was 
Probably  an  Important  Etiologic  Factor  but  in  Which 
Marked  Relief  Followed  Freeing  of  Nerve 
Trunks  from  Pressure  by  Cicatri- 
cial Tissue 

In  this  case  of  Leonard  Freeman's  the  patient  was  a  fe- 
male, lo  years  of  age,  who  had  had  both  bones  of  her  forearm 
broken.  SpHnts  had  been  applied  for  four  weeks  and  a  plaster 
of  Paris  cast  for  several  weeks  longer.  Freeman  found  sev- 
eral pressure  necrosis  scars,  and  that  the  skin,  which  was 
cyanotic,  drawn,  and  glazed,  "was  almost  completely  anes- 
thetic." The  fingers  were  strongly  contracted,  the  muscles 
of  the  forearm  indurated  and  paralyzed,  and  the  hand  useless. 
On  operating  the  median  nerve  was  found  to  be  pinched  by 
the  cicatrized  pronator  radii  teres,  the  ulnar  nerve  less  so  by 
the  flexor  carpi  ulnaris,  and  the  radial  nerve  slightly,  if  at  all, 
involved.  Above  the  points  of  compression  the  nerves  were 
normal,  below  they  were  hardened  and  small.  They  were 
freed  with  the  result  that  "steady  improvement  followed  until, 
at  the  end  of  three  months,  during  which  time  massage  was 
employed,  sensation  and  motion  in  the  hand  were  almost  com- 
plete and  the  circulatory  and  trophic  disturbance  had  disap- 
peared. .  .  .  Three  years  after  the  operation  the  hand  and 
arm  were  in  nearly  perfect  condition,  with  no  atrophy  or  in- 
duration of  the  muscles,  with  full  motion  of  the  fingers,  and 
normal  nerve  function." 

In  the  above  case,  in  spite  of  the  fact  that  undue  pressure 
doubtless  played  an  important  part  in  causing  the  condition, 
there  can  be  little  doubt  that  part  of  the  deformity,  and  prob- 
ably a  large  part,  was  played  by  the  compression  of  the  nerve 
trunks.  This  is  indicated  by  the  very  definite  compression  and 
by  the  persistence  of  the  contracture  until  the  compression  was 


ISCHEMIC  PARALYSIS  141 

removed  and  by  the  subsequent  disappearance  of  the  symp- 
toms. The  good  ultimate  results  are  in  contrast  with  the  com- 
paratively poor  ultimate  results  in  two  other  cases  reported  by 
the  same  author,  in  both  of  which  there  was  definite  pinching 
of  important  nerve  trunks.  An  explanation  is  readily  found, 
however,  in  the  fact  that  in  these  two  cases  operation  was  de- 
ferred until  one  and  two  and  one-half  years,  respectively, 
after  the  injury,  while  in  the  above  case  it  was  done  after  "four 
weeks  plus  several  weeks  longer."  As  would  be  expected,  the 
earlier  the  operation  the  less  the  permanent  injury  in  such  a 
case.  J.  J.  Thomas,  of  Boston,  in  his  compilation  of  107  cases, 
reports  60  per  cent,  with  nerve  injury,  and  doubtless  there 
was  a  larger  percentage  than  that  even  on  account  of  cases  in 
which  no  report  of  nerve  injury  was  made. 

That  a  certain '  number  of  cases  of  ischemic  paralysis  and 
contracture  give  direct  evidence  that  they  do  not  stop  far 
short  of  actual  gangrene  is  shown  by  a  certain  number  of 
the  clinical  reports.  Thomas  found  37  out  of  107  cases  in 
which  "various  trophic  changes,  such  as  coldness,  cyanosis, 
shiny  skin,  ulcers  on  the  fingers,  or  blebs,  were  present." 
That  gangrene  may  actually  occur  following  tight  bandaging 
without  contracture  is  shown  by  the  following  cases: 

4A.     Case  in   Which  Bandaging  for   Uncomplicated  Potfs 

Fracture  Was  Followed  by  Gangrene,  Necessitating 
Amputation 

The  details  of  this  case  were  kindly  furnished  in  a  personal 
communication  from  Dr.  E.  H.  Season.  The  patient,  a  man 
about  40  years  of  age,  was  thrown  from  his  horse  while  rid- 
ing in  the  mountains  of  West  Virginia  and  sustained  a  simple 
Pott's  fracture.  It  was  put  up  in  the  usual  way,  and  the  fol- 
lowing night  a  great  deal  of  pain  occurred,  the  bandages 


142  SURGICAL  ANEMIA  AND  RESUSCITATION 

clearly  being  too  tight.  The  bandages  were  not  removed  for 
forty-eight  hours,  when  it  was  found  that  gangrene  had  begun 
to  develop,  which  later  necessitated  amputation  at  the  knee. 

4B.     Case  in  Which  Beginning  Gangrene  of  the  Hand  Fol- 
lowed Prolonged  Application  of  a  Tight  Sleeve 

This  case,  reported  by  Nevitt,  concerned  a  boy,  3^/2  years 
of  age,  who  had  been  restless  and  cross  for  several  days,  and 
complained  of  his  hand,  which  had  become  swollen  and  pain- 
ful. When  first  seen  by  Nevitt  he  found  the  "hand  and  fore- 
arm greatly  swollen  and  of  a  mottled  purplish  color;  the 
swollen  parts  felt  quite  cold;  there  was  a  spot  about  the  size 
of  a  twenty-five-cent  piece  on  the  palm  opposite  the  roots  of 
the  middle  and  ring  fingers  which  had  become  quite  gangren- 
ous. On  examination  it  was  found  that  constriction  was 
caused  above  the  elbow  by  a  rather  tight  sleeve,  which,  there 
is  every  reason  to  believe,  had  not  been  removed  since  the 
child  had  first  complained  of  pain  .  .  ."  With  the  idea  of 
relieving  tension  an  incision  was  made  in  the  palm.  There 
was  scarcely  any  bleeding,  but  a  considerable  quantity  of 
blood-stained  serum  escaped.  Hot  linseed  poultices  were  ap- 
plied, and  after  nine  days  complete  recovery  of  sensation  had 
occurred  and  free  movement  of  the  fingers  was  possible. 

Either  one  of  the  above  two  cases  could  conceivably  have 
ended  in  contracture.  The  important  question  is,  how  many 
such  cases  have  occurred,  and,  because  they  have  gone  as  far 
as  gangrene,  have  masked  the  condition  of  contracture,  and, 
hence,  have  never  been  reported  as  such. 

CONCLUSIONS 

Clinically  it  is  evident  that  ischemic  contracture  is  most 
often  due  to  the  too  tight  application  of  splints  or  bandages; 
that  anemia  results  from  the  pressure  so  induced;  that  what. 


ISCHEMIC  PARALYSIS 


143 


until  we  have  a  clearer  understanding,  we  may  call  coagulation 
of  the  muscle  proteids  takes  place;  and  that  degeneration  of 
the  muscle  elements  occurs  along  with  proliferation  of  the 
connective  tissue  elements.  As  has  been  shown  in  the  cases 
cited  above,  anemia  alone,  nerve  injury  alone,  or  both  in 
combination  may  cause  muscular  contractures,  so  that  pressure 
is  not  an  essential  factor,  although  usually  present.  As  in 
anemia  of  any  part  of  the  body,  there  is  a  certain  time  limit 
within  which  muscle  and  nerve  elements  may  undergo  com- 
plete anemia  with  complete  recovery.  There  is  a  longer  time 
during  which  these  elements  may  undergo  partial  anemia  with 
complete  recovery.  According  to  the  observations  of  Stewart 
and  others,  the  endings  of  the  motor  nerves  are  the  first  to 
succumb  to  any  given  degree  of  anemia,  while  the  muscle 
fibers  are  more  resistant. 

As  a  corollary  of  the  above  statements  it  is  evident  that 
the  less  the  degree  of  anemia  the  less  the  permanent  injury  to 
muscles  and  nerves ;  that  causes  of  contracture  and  impairment 
of  nerve  function  generally  should  not  be  necessarily  ascribed 
to  anemia  alone  (in  fracture  cases  particularly  nerve  injuries 
should  be  sought  for  early  and  also  late — they  may  be  caused 
by  trauma  at  first  and  by  compression  later),  and  that  opera- 
tive interference  should  be  as  early  as  possible.  In  children 
particularly  the  greatest  care  should  be  used  to  avoid  undue 
pressure  in  treating  fractures  or  any  other  injuries  of  the  ex- 
tremities. 


CHAPTER  VII 

CLINICAL  APPLICATIONS  FROM  THE  FOUR  PREVIOUS  CHAPTERS. 

LOCAL   GANGRENE   FROM   ANEMIA   OF  THE    EXTERNAL 

SOFT  PARTS  OF  THE  BODY 

Anemia  from  direct  pressure  occurs  most  commonly  in  the 
course  of  the  treatment  of  fractures,  in  anesthetic  parts  fol- 
lowing hemiplegia,  in  prolonged  wasting  illnesses  of  any  kind 
(bedsores),  in  skin  flaps  under  too  great  tension;  as  a  result 
of  cross  lesions  of  the  spinal  cord,  occasionally  as  a  result  of 
too  long-continued  saline  infusion  in  unconscious  patients  (as, 
for  example,  in  typhoid  fever),  of  forgotten  bandages  or  of 
tight-fitting  rings,  and  of  sutures  too  tightly  tied.  Again, 
local  anemia  may  be  due  to  interference  with  the  arterial  blood 
supply  by  the  direct  pressure  of  neoplasms  on  the  vessels  as 
well  as  by  embolism,  thrombosis,  obliterating  arteritis,  and  by 
nervous  vascular  contraction. 

ERRORS  IN  THE  TREATMENT  OF  FRACTURES 

In  the  immediate  treatment  of  simple  fractures  before 
swelling  has  taken  place,  despite  almost  universal  warning 
against  the  practice,  one  still  sees  the  .application  of  padded 
splints  over  a  bandage  which  is  directly  over  the  skin.  In  such 
a  case  if  the  patient  is  fortunate  in  reaching  his  physician 
before  total  gangrene  of  the  soft  parts  has  occurred,  or  if  he 
has  courage  enough  to  remove  the  dressings  himself,  all  will 
be  well;  but,  on  the  other  hand,  after  a  period  of  intense  pain 
may  come  the  comforting  anesthesia  of  gangrene,  and  when 

144 


ERRORS  IN  TREATMENT  OF  FRACTURES        145 

next  the  limb  is  examined  both  patient  and  physician  realize 
the  disaster  which  has  occurred. 

As  already  indicated,  the  skin,  the  muscles,  the  tendons, 
and  the  bones  vary  in  their  resistance  to  anemia.  Total 
anemia  may  be  so  timed  that  the  muscles  may  die  and  the  skin 
and  the  bones  live.  The  bones,  however,  are  in  a  position  of 
advantage,  as  that  part  of  their  blood  supply  which  is  delivered 
through  the  medulla  may  escape  the  direct  pressure  of  the 
constricting  bandage.  In  other  instances  anemia  kills  all  of 
the  soft  parts  down  to  the  bones  and  the  patient  is  compelled 
to  accept  amputation  as  the  only  way  out  of  his  unmerited 
misfortune.  Even  if  no  bandage  is  applied  directly  over 
the  skin,  splints  inadequately  padded,  or,  if  adequately  padded, 
applied  too  tightly  and  for  too  long  a  time,  may  cause  local 
death  of  tissue  from  anemia.  Perhaps  one  group  of  muscles 
or  only  the  prominent  bony  points  may  be  involved.  The 
points  most  commonly  suffering  from  this  cause  are  the  heel, 
the  malleoli,  and  the  condyles.  Of  these  minor  points  the  heel 
causes  the  most  trouble,  the  soft  tissues  usually  sloughing 
down  to  the  bone  with  sometimes  death  of  the  superficial 
part  of  the  bone  also.  Repair  in  this  dense  tissue  may  be 
extremely  tardy,  especially  when  the  bone  is  involved. 

It  is  evident,  therefore,  that  under  no  circumstances 
should  a  bandage  be  applied  directly  over  the  skin  in  the 
treatment  of  fractures;  that  all  splints  or  restraining  apparatus 
should  be  protected  with  an  abundance  of  elastic  cotton  or 
wool;  and  that  the  bandage  pressure  should  be  applied  cau- 
tiously. The  patient  should  be  especially  requested  to  give 
notice  of  undue  pain,  and,  finally,  such  warnings  should  in- 
variably lead  to  an  investigation  by  the  attending  physician.  It 
may  not  be  amiss  to  restate  here  the  well-known  fact  that  the 
key  to  the  successful  treatment  of  fractures  is  proper  reduction 
in  the  first  instance,  not  omitting  in  the  great  majority  of 


146  SURGICAL  ANEMIA  AND  RESUSCITATION 

cases  the  advantage  of  reduction  under  anesthesia,  so  that 
correct  position  may  be  retained  with  a  minimum  of  splint 
restraint,  pain,  and  swelling.  The  time  is  past  when  it  was 
considered  good  practice  to  try  to  overcome  the  deformity  by  a 
feeble  attempt  at  direct  pressure  with  apparatus;  that  correc- 
tion should  be  made  in  the  first  instance  under  anesthesia.  If 
the  reduction  cannot  be  made  in  such  a  manner  that  proper 
mechanical  aids  will  maintain  a  good  position,  then  imme- 
diate fixation  with  plates  should  be  considered. 

A  great  factor  in  the  death  of  tissue  from  mechanical  pres- 
sure is  the  fact  that,  on  account  of  the  injury  and  the  swelling, 
and  sometimes,  too,  because  of  the  lowered  general  blood- 
pressure  from  shock,  the  circulation  is  especially  apt  to  be 
arrested  locally. 

ANEMIA  IN  LESIONS  OF  THE   SPINAL  CORD 

There  is  probably  no  higher  testimony  to  the  state  of 
efficiency  of  a  surgical  service  than  the  degree  of  success  ob- 
tained in  the  care  of  patients  with  complete  cross  lesions  of 
the  spinal  cord.  The  very  difficulty  of  preventing  bedsores  is 
a  reminder  of  the  beneficent  effect  of  the  pain  which  is  a  con- 
stant protection  against  local  death  from  anemia.  While  the 
loss  of  the  warning  of  pain  is  the  principal  cause  of  bed- 
sores, there  is  another  factor  that  enters  strongly  into 
their  formation,  viz.,  the  cross  lesion  of  the  spinal  cord  not 
only  breaks  the  motor  and  sensory  connections  with  the  brain 
and  the  periphery,  but  breaks  also  the  vasomotor  connection. 
The  break  in  the  vasomotor  connection  at  once  removes  nerve 
control  from  the  blood  vessels  of  the  parts  beyond  the  broken 
point,  and,  hence,  these  vessels  lose  their  tone.  In  consequence 
there  is  a  large  fall  in  the  general  blood-pressure.  That  this 
fall  is  not  temporary  is  shown  by  the  record  of  a  clinical  case 


ANEMIA  IN  Lesions  of  the  spinal  cord  147 

two  and  one-half  months  after  the  cord  was  severed,  the  low 
pressure  having  persisted  until  that  time. 

The  general  low  blood-pressure  due  to  a  cross  lesion  plays 
an  important  role  in  the  formation  of  bedsores,  for,  if  the 
blood-pressure  has  fallen  to  one-half  its  normal  height,  it  is 
found  by  experience  that  even  a  very  soft  bed  may  not  be  a 
sufficient  protection.  Under  some  conditions  a  bedsore  may 
form  even  when  the  patient  is  on  a  water-bed. 

Just  what  is  the  mechanism  of  the  formation  of  the  bed- 
sore ?  Why  is  there  almost  always  a  period  of  redness  of  the 
skin  that  precedes  the  bedsore  itself  ?  Why  does  it  usually  ex- 
tend down  to  the  bone,  and  why  does  it  stop  just  at  the 
high  bony  points  and  not  extend  between  these  points?  The 
sequence  of  change  could  not  well  be  otherwise,  because  the 
skin  endures  total  anemia  longer  than  the  subcutaneous  tissue, 
and  the  various  types  of  subcutaneous  tissue  found  in  the 
region  endure  anemia  about  equally  well.  The  pressure  on 
the  bony  points  is  just  the  same  as  that  on  the  skin,  hence  all 
of  the  soft  parts  between  the  bone  and  the  skin  are  subjected 
to  an  equal  pressure,  and  are  about  equally  susceptible  to  ane- 
mia, and  all  the  parts  between  the  skin  and  the  bone  succumb. 
There  is  first  aseptic  necrosis,  but  soon,  most  likely  through  the 
skin,  there  is  infection  to  which  the  impaired  tissue  readily  suc- 
cumbs.    The  sequence  of  events  following  infection  is  obvious. 

The  frequent  application  of  alcohol  apparently  is  of  value 
in  preventing  the  formation  of  bedsores.  If  alcohol  were 
applied  by  strict  rule  every  four  hours  it  would  be  a  specific 
preventative.  So,  too,  would  turning  the  patient  over  once 
every  four  hours  be  a  specific  preventative  without  the  use 
of  alcohol.  The  mere  relief  from  pressure  at  such  intervals, 
especially  if  accompanied  by  local  rubbing  to  renew  the  cir- 
culation, would  in  itself  be  sufficient..  But  the  application  of 
alcohol  has  another  good  effect,  viz.,  it  may  and  probably  does 


148  SURGICAL  ANEMIA  AND  RESUSCITATION 

assist  in  keeping  down  infection  especially  in  the  deeper  parts 
of  the  skin.     - 

The  most  important  point  to  bear  in  mind  is  that  when 
there  is  uninterrupted  total  anemia  of  six  hours,  for  example, 
certain  tissues  are  then  and  for  all  time  dead,  and  as  the  dura- 
tion of  total  anemia  is  increased  still  other  types  of  tissue 
die.  A  patient  may  progress  favorably  for  as  long  as  a  month 
and  then  the  price  of  one  error  may  be  the  much  dreaded  bed- 
sore. The  absolute  protection  of  such  patients  would  be 
further  guaranteed  by  the  use  of  an  automatic  signal  that 
would  continue  an  annoying  warning  until  turned  off  by  the 
nurse  only  at  the  bedside  of  the  patient,  thus  insuring  exact 
periodic  attendance  on  the  patient. 

SALINE  INFUSIONS 

In  three  instances  the  author  has  seen  the  long-continued 
use  of  saline  infusions  under  the  breast  cause  gangrene,  twice 
in  unconscious  typhoid  patients  who  had  had  hemorrhages, 
and  in  another  instance  in  a  patient  unconscious  from  shock 
and  hemorrhage.  In  these  cases  the  sequence  of  events  was 
just  the  same  as  that  seen  in  bedsores.  Some  time  after  the 
saline  solution  was  introduced  there  were  local  swelling,  ten- 
derness, redness,  and  heat.  Later  an  abscess  developed  which 
ended  in  the  breaking  down  of  a  zone  of  tissue  as  wide  and 
as  deep  as  the  area  from  which  the  blood  supply  had  been 
driven  out  by  the  force  of  the  pressure  from  the  infusion 
bottle.  In  these  cases  it  must  be  borne  in  mind  that  a  low 
general  blood-pressure  renders  it  all  the  more  easy  to 
force  the  normal  blood  supply  out  of  any  tissue.  Because 
the  urgent  need  for  saline  infusion  usually  occurs  in  just  such 
a  condition  of  the  circulation  as  renders  the  tissues  susceptible 
it  is  essential  that  it  be  given  with  great  care.     Continuous 


FLAP    TENSION    AND    SUTURE    TENSION  149 

or  interrupted  massage  as  a  part  of  the  process  of  subcutaneous 
infusion  is  not  only  a  protection  against  the  total  exclusion  of 
blood  from  the  part  but  materially  increases  the  rate  of  ab- 
sorption and  lessens  the  local  pain  and  discomfort. 

FLAP  TENSION  AND   SUTURE  TENSION 

Among  the  most  common  errors  of  the  rougher  surgery 
in  vogue  in  the  past,  and,  unhappily,  an  error  which  is  occa- 
sionally seen  still,  was  that  of  tight  tying  of  stitches.  This 
was  especially  true  in  wounds  in  which  there  was  a  scanty  or 
an  ill-fashioned  flap.  Under  these  circumstances  stitches 
were  expected  to  do  what  finesse  had  failed  to  do.  The  results 
were  sudden  pain,  infection,  anemia  of  the  area  with  necrosis, 
failure  of  union,  a  gaping  wound,  disappointment  for  the 
patient  and  well-earned  humiliation  for  the  surgeon.  In  many 
instances  conditions  require  a  stitch  to  carry  an  unusual 
amount  of  strain,  e.  g.,  in  the  wall  of  a  distended  or  an  unusu- 
ally large  abdomen,  and  in  the  perineum.  Whenever  a  stitch 
is  thus  taxed  with  more  than  the  ordinary  tension  it  should  be 
shielded  with  rubber  tubing  (Stiles),  gauze,  or  other  material. 

In  perineal  stitches  the  author  has  found  that  such  protec- 
tion of  the  stay  sutures  not  only  prevents  cutting,  but  also  pre- 
vents much  of  the  discomfort  that  so  frequently  attends  this 
operation.  Then,  too,  it  is  a  point  well  worth  remembering 
when  stay  sutures  are  used  and  the  circumstances  demand  a 
mattress  stitch,  that  the  mattress  grasp  should  be  placed  on  a 
line  vertical  to  the  wound  and  not  parallel  to  it,  as  it  is  obvious 
that  the  parallel  pressure  might  lead  to  anemia  of  the  adjacent 
skin.  When  tension  sutures  are  demanded,  a  buried  catgut 
suture  is  less  liable  to  cause  suppuration  by  causing  anemia 
in  bits  of  subcutaneous  tissue  than  it  would  in  bits  of  skin. 
There  is  also  less  discomfort  resulting,  from  subcutaneous  ten- 
sion than  from  skin  tension. 


CHAPTER  VIII 

ANEMIA  OF  THE  SMALL  INTESTINE  :     EXPERIMENTAL  OBSERVA- 
TIONS.      INTERFERENCE   WITH    THE    CIRCULATION    OF 
LOOPS  OF  SMALL  INTESTINE  OF  DOGS  FOR  DIFFER- 
ENT LENGTHS  OF  TIME  UNDER  DIFFERENT 
CONDITIONS 

In  Collaboration  with  Dr.  A.  M.  Tweedie  and  Dr.  H.  G.  Sloan 

All  of  the  following  experiments  were  performed  under  as 
rigid  asepsis  as  possible.  Ether  was  used  for  anesthesia,  and 
morphia  usually  with  it,  or  as  indicated  after  the  operation. 
The  experiments  were  divided  into  eight  groups  as  follows  : 

I.  Those  in  which  a  loop  of  small  intestine  with  its  blood 
vessels  was  ligated  en  masse  with  tape,  the  tape  being  removed 
before  the  abdomen  was  closed. 

II.  Those  in  which  a  loop  of  intestine  was  ligated  as  be- 
fore, a  lateral  anastomosis  having  previously  been  made  to 
isolate  the  loop,  and  the  tape  removed  before  closing  the  ab- 
domen. This  eliminated  intestinal  obstruction  except  in  the 
loop,  and  in  the  obstructed  loop  constriction  existed  only 
while  the  tape  was  allowed  to  remain  in  place. 

III.  Those  in  which  the  lateral  anastomosis  was  made,  the 
loop  ligated,  and  the  tape  left  in  place  when  the  abdomen  was 
closed.  The  object  of  leaving  the  tape  in  place  was  to  see 
whether  or  not  the  toxic  material  could  l)e  kept  out  of  the 
circulation. 

150 


152  SURGICAL  ANEMIA  AND  RESUSCITATION 

.IV.  Those  in  which  the  lateral  anastomosis  was  made, 
the  loop  ligated,  and  the  loop  excised  at  the  end  of  the  period 
of  anemia  before  closing  the  abdomen. 

V.  Those  in  which  the  lateral  anastomosis  was  made,  the 
loop  ligated,  a  drainage  tube  inserted  into  the  loop,  and  the 
abdomen  closed. 

VI.  Those  in  which  the  lateral  anastomosis  was  made, 
the  loop  ligated,  and  the  loop  allowed  to  project  through  the 
abdominal  wound.  The  object  was  to  allow  the  loop  to 
slough  away  outside  of  the  abdomen. 

VII.  Those  in  which  there  was  partial  occlusion  of  the 
blood  supply  of  a  loop  by  ligating  mesenteric  arteries  and 
veins. 

VIII.  Those  in  which  control  animals  were  operated  on 
without  ligating  the  intestine. 

Group  I 

Experiments  in  Which  a  Loop  of  Small  Intestine  udth  Its 

Blood  Vessels  Was  Ligated  en  Masse  zvith  Tape,  the 

Tape  Being  Removed  Before  the  Abdomen 

Was  Closed 

EXPERIMENT    i 

November  9,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  J4-  A  15  cm. 
loop  of  small  intestine,  with  its  mesentery,  was  ligated  en  masse  with 
tape.  At  the  end  of  /  hour  the  tape  was  removed  and  the  abdomen 
closed.  At  this  time  the  circulation  could  be  seen  to  return  to  the 
loop.  The  dog  died  fifteen  hours  after  stopping  the  anesthesia.  The 
cause  of  death  was  not  determined.  There  was  marked  congestion 
of  the  portions  of  the  intestine  handled  in  carrying  out  the  technique 
but  the  loop  showed  no  gross  changes. 

EXPERIMENT    2 

November  10,  1908. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  %.  A 
15  cm.  loop  of  intestine  was  ligated,  as  before,  at  a  point  about  30  cm. 


ANEMIA  OF  THE  SMALL  INTESTINE  153 

from  the  cecum.     At  the  end  of  /  hour  the  tape  was  removed,  and 
the  abdomen  closed. 

November  12. 

The  bitch  appeared  to  be  well.  Nothing  abnormal  was  apparent, 
except  a  slight  discharge  from  the  wound. 

November  23. 

Condition,  normal. 

January  4,  1909. 

The  bitch  was  chloroformed.  No  gross  changes  were  found  in 
the  loop. 

EXPERIMENT    3 

November  13,  1908. 

Pug  bitch ;  condition,  good.  Ether ;  morphia,  gr.  54-  A  30  cm. 
loop,  about  90  cm.  from  the  pylorus,  was  ligated.  At  the  end  of 
I  hour  the  tape  was  removed,  and  the  abdomen  closed.  Recovery 
from  the  operation  was  good. 

November  17. 

The  bitch  was  in  good  condition. 

January  i,   1909. 

Condition,  the  same. 

January  7. 

The  bitch  was  killed  in  a  resuscitation  experiment,  and  sections 
of  the  intestine  were  taken  for  staining.  Many  adhesions  were  pres- 
ent around  the  loop,  but  otherwise  no  gross  changes  were  present. 
The  histologic  examination  was  negative. 

EXPERIMENT    4 

January  16,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  j/j.  A  15  cm. 
loop  near  the  cecum  was  ligated.  After  /  hour  the  tape  was  re- 
moved, and  the  abdomen  closed. 

February  13. 

Complete  recovery, 

EXPERIMENT    5 

November  12,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  }^.  A 
17  cm.  loop  was  ligated  at  a  point  about  30  cm.  from  the  cecum.  At 
the  end  of  2  hours  the  tape  was  removed,  and  the  abdomen  closed. 
Recovery  from  the  operation  was  good. 


154  SURGICAL  ANEMIA  AND  RESUSCITATION 

November  13. 

The  dog  was  sick,  but  did  not  vomit.  The  bowels  had  not  moved 
since  the  operation. 

November  16. 

The  dog  was  still  sick,  but  still  had  not  vomited.  There  was 
some  discharge  from  the  abdominal  incision.  The  wound  was  cleared, 
and  a  moist  bichlorid  of  mercury  dressing  applied.  Rectal  tempera- 
ture, 38.9°  C. 

November  17. 

The  dog  was  very  sick.  Temperature,  38.9°.  Heart  action  rapid. 
The  abdomen  was  tender,  there  was  a  foul  discharge  from  the  wound, 
and  the  dog  vomited  occasionally. 

November  18. 

Death  occurred  during  the  night.  At  the  autopsy  acute  peritoni- 
tis was  found,  and  a  perforation  at  the  point  of  ligation.  The  loop 
was  markedly  congested,  but  how  much  from  the  ligation,  and  how 
much  from  the  peritonitis,  could  not  be  determined. 

EXPERIMENT    6 

November  13,  1908. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  ^.  A 
15  cm.  loop,  about  120  cm.  from  the  pylorus,  was  ligated.  At  the 
end  of  2  hours  the  tape  was  removed,  and  the  abdomen  closed.  Re- 
covery from  the  operation  was  good. 

November  15. 

The  general  condition  was  good.  There  had  been  no  vomiting, 
and  the  bowels  had  not  moved  since  the  operation. 

November  17. 

General  condition,  good.  The  wound  was  clean.  The  bowels 
moved.    Temperature  normal. 

January  6,   1909. 

The  bitch  was  chloroformed.  The  autopsy  revealed  many  adhe- 
sions about  the  loop.  The  microscopical  examination  of  the  section 
from  the  loop  showed  an  old  adhesion  of  the  tunica  serosa,  but  there 
were  no  signs  of  change  other  than  this. 

EXPERIMENT  7 

November  28,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  A  20  cm. 
loop,  midway  between  the  jejunum  and  the  cecum,  was  ligated.    After 


ANEMIA  OF  THE  SMALL  INTESTINE  155 

2^  hours  the  tape  was  removed,  and  the  abdomen  closed.  The  dog 
recovered  from  the  operation  well,  but  died  during  the  night.  The 
autopsy  showed  deep  congestion  of  all  the  parts  that  were  handled 
during  the  operation.  The  loop  showed  evidence  of  return  of  cir- 
culation. 

EXPERIMENT    8 

December  5,  1908. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gv.  j4.  A 
25  cm.  loop  of  small  intestine  was  ligated.  After  j  hours  the  tape 
was  removed,  and  the  abdomen  was  closed.  At  this  time  a  slight 
return  of  the  circulation  could  be  seen. 

December  6. 

Condition,  good.     Wound,  clean.     No  vomiting.     Refused  to  eat. 

December  7. 

Condition,  good.    Appetite,  good.    The  bowels  had  not  moved. 

December  8. 

Condition,  good.     The  bowels  moved  during  the  night. 

December  10. 

Condition,  good.    The  wound  was  clean. 

December  24. 

Death  occurred  during  the  night,  cause  undetermined.  The 
autopsy  findings  were  negative  except  for  the  fact  that  adhesions 
were  present  around  the  loop.     The  loop  itself  was  normal. 

EXPERIMENT    9 

February  8,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^.  A  10  cm. 
loop  near  the  jejunum  was  ligated.  At  the  end  of  4  hours  the  tape 
was  removed,  and  the  abdomen  closed.  Shortly  after  this  the  dog 
died  from  the  effects  of  the  anesthetics.     The  autopsy  was  negative. 

EXPERIMENT    10 
December  ii,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^.  A  15  cm. 
loop,  30  cm.  from  the  pylorus,  was  ligated.  After  4  hours  the  tape 
was  removed,  and  the  abdomen  closed.  The  recovery  from  operation 
was  good. 

December  12. 

The  wound  was  clean,  and  the  general  condition  good.  There 
was  no  vomiting.    The  bowels  had  not  moved. 


156  SURGICAL  ANEMIA  AND  RESUSCITATION 

December  15. 

General  condition,  good.     The  bowels  moved  during  the  night. 

December  20. 

The  dog  was  found  dead.  At  autopsy  about  90  cm.  of  the  small 
intestine  were  found  to  be  deeply  congested,  looking  as  if  arterial 
thrombosis  had  occurred.  There  were  some  adhesions  about  the  loop, 
but  the  loop  itself  showed  every  evidence  of  return  of  circulation. 

Microscopical  Examination. — But  few  changes  were  found  in 
the  sections  studied.  There  was  some  desquamation  of  the  epithelium 
in  the  gland  crypts,  and  the  tunica  serosa  showed  numerous  adhe- 
sions. Otherwise  a  normal  appearance  was  presented.  (See  Figs. 
Ill  and  IV.) 

EXPERIMENT    11 
January  23,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  V^.  A  30  cm. 
loop,  just  below  the  jejunum,  was  ligated.  At  the  end  of  5  hours  the 
tape  was  removed,  and  the  abdomen  closed.  The  dog  was  in  good 
condition  when  removed  from  the  table. 

January  24. 

Death  occurred  during  the  night.  At  the  autopsy  the  loop  was 
found  to  be  gangrenous.     Otherwise  the  autopsy  was  negative. 

EXPERIMENT    12 

January  24,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  J4-  A  15  cm. 
loop,  about  90  cm.  from  the  pylorus,  was  ligated.  After  5  hours  the 
tape  was  removed,  and  the  abdomen  closed. 

January  5. 

General  condition,  good.  The  bowels  had  not  moved,  but  there 
was  no  vomiting  or  abdominal  distention. 

January  6. 

The  bowels  had  moved  during  the  night.  In  the  stool  there  w«as 
some  blood-streaked  mucus.     General  condition,  good. 

January  7. 

The  dog  appeared  to  be  normal  in  every  way. 

January  ii. 

The  dog  was  chloroformed.  At  the  autopsy  the  loop  appeared  to 
be  normal  except  for  a  few  adhesions. 

Microscopical  Examination. — Extensive  desquamation  of  the 
epithelium  lining  the  follicles  and  hemorrhage  into  the  mucosa  were 


158  SURGICAL  ANEMIA  AND  RESUSCITATION 

found.     Throughout  the  sections  there  were  interstitial  hemorrhages 
and  round-cell  infiltration.     There  was  no  tissue  necrosis,  however. 

EXPERIMENT    13 

January  5,  1909. 

Bulldog  bitch;  condition,  good.  Ether;  morphia,  gr.  J4-  A 
20  cm.  loop,  about  90  cm.  from  the  jejunum,  was  ligated.  At  the  end 
of  6  hours  the  tape  was  removed,  and  the  abdomen  closed.  The  re- 
covery from  the  operation  was  good. 

January  6. 

General  condition,  very  poor.  The  heart  sounds  were  scarcely 
perceptible.  There  was  no  abdominal  distention,  or  vomiting,  and 
the  wound  was  clean.  The  condition  seemed  to  be  one  of  rapidly 
progressing  extreme  exhaustion.  Pulse,  180.  Rectal  temperature, 
subnormal.  Death  occurred  at  9 130  a.  m.,  about  twenty- four  hours 
after  the  operation.  At  the  autopsy  the  peritoneum  was  found  to  be 
slightly  congested.  There  was  no  free  fluid  in  the  abdominal  cavity. 
The  loop  was  gangrenous. 

EXPERIMENT    14 

January  16,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  A  20  cm. 
loop  near  the  jejunum  was  ligated.  After  6  hours  the  tape  was  re- 
moved, and  the  abdomen  closed. 

January  17. 

The  dog  was  found  dead.  At  autopsy  the  peritoneum  was  found 
to  be  congested,  and  part  of  the  ligated  loop  was  gangrenous.  There 
was  no  free  fluid  in  the  abdominal  cavity. 

EXPERIMENT    15 

December  i,  1908. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^.  A  15  cm. 
loop,  about  60  cm.  from  the  jejunum,  was  ligated.  At  the  end  of 
6  hours  the  tape  was  removed,  and  the  abdomen  closed.  During  the 
time  that  it  was  constricted  the  loop  became  very  dark,  and  there 
was  no  evidence  that  the  circulation  was  restored  when  the  tape  was 
removed.  , 

December  2. 

Death  occurred  during  the  night,  and  at  the  autopsy  the  loop  was 
found  to  be  gangrenous.  The  peritoneum  was  somewhat  congested. 
Sections  were  not  made. 


ANEMIA  OF  THE  SMALL  INTESTINE  159 

EXPERIMENT    i6 
January  17,  1909. 

Mongrel  dog;  condition,  good.    Ether;  morphia,  gr.  5^4.     A  15  cm. 

loop,  90  cm.   from  the  cecum,  was  ligated.     At  the   end  of  6  hours 

the  tape  was  removed,  and  the  abdomen  closed. 

January  iS. 

General  condition,  poor,  there  being  extreme  exhaustion.  Rectal 
temperature,  36.7°.  Pulse,  150.  Heart  action,  very  w'eak.  The 
bowels  had  not  moved,  but  there  was  no  abdominal  distention. 

January  20. 

Death  occurred  during  the  night.  The  autopsy  revealed  some 
congestion  of  the  peritoneum,  and  of  the  intestines,  which  had  been 
handled.  The  loop  showed  some  evidence  of  returning  circulation,  as 
it  was  less  gangrenous  than  in  the  experiments  in  which  circulation 
was  obstructed  for  a  longer  time. 

EXPERIMENT    17 

January  20,  1909. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  ^.  A 
30  cm.  loop,  about  15  cm.  from  the  jejunum,  was  ligated.  After 
6  hours  the  tape  was  removed,  and  the  abdomen  closed.  One-half 
hour  after  the  operation  was  over  death  occurred.  The  autopsy 
showed  that  there  had  been  no  return  of  circulation  in  the  loop. 
(See  Figs.  V  and  VI.) 

EXPERIMENT    18 

January  6,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^.  A  25  cm. 
loop,  about  30  cm.  from  the  cecum,  was  ligated.  After  8  hours  the 
tape  was  removed,  and  the  abdomen  closed. 

January  7. 

The  dog  was  in  a  state  of  collapse,  and  vomited.  The  pulse  rate 
was  about  170,  the  heart  action  being  scarcely  perceptible  to  palpa- 
tion. Rectal  temperature,  36.1°  C.  During  the  afternoon  death  oc- 
curred. Just  before  death  there  was  a  slight  convulsion.  At  the 
autopsy  the  loop  was  found  to  be  gangrenous.  Otherwise  the  find- 
ings were  negative. 

EXPERIMENT    19 

January  7,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^A.  A  15  cm. 
loop,  midway  between  the  jejunum  and  the  cecum,  was  ligated.    After 


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ANEMIA  OF  THE  SMALL  INTESTINE  i6l 

8  hours  the  tape  was  removed,  and  the  abdomen  closed.     The  animal 
made  a  good  recovery  from  the  operation. 

January  8. 

The  dog  was  found  dead.  At  the  autopsy  the  loop  was  found  to 
be  gangrenous.    The  other  organs  were  negative. 

EXPERIMENT    20 
January  8,  1909. 

Black  and  tan  bitch;  condition,  good.  Ether;  morphia,  gr.  ^.  A 
15  cm.  loop  near  the  cecum  was  ligated.  At  the  end  of  8  hours  the 
tape  was  removed,  and  the  abdomen  closed.  The  bitch  was  in  good 
condition  when  taken  from  the  operating  table. 

January  9. 

Death  occurred  during  the  night.  The  autopsy  showed  no 
changes  further  than  gangrene  of  the  loop. 

EXPERIMENT    21 
January  ii,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  5^2 .  A  7  cm. 
loop,  about  30  cm.  from  the  jejunum,  was  ligated.  After  8  hours  the 
tape  was  removed,  and  the  abdomen  closed.  The  operative  recovery 
was  good. 

January  12. 

The  dog  was  in  a  state  of  great  prostration,  with  abdominal  dis- 
tention and  vomiting.  The  bowels  had  not  moved.  The  temperature 
was  subnormal,  36.4°  C,  and  the  heart  action  very  weak. 

January  13. 

Death  occurred  during  the  night.  The  autopsy  revealed  nothing 
but  gangrene  of  the  loop. 


EXPERIMENT    22 
January  22,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  3^.  ■  A  15  cm. 
loop,  about  90  cm.  from  the  pylorus,  was  ligated.  After  8  hours  and 
15  minutes  the  tape  was  removed,  and  the  abdomen  closed.  The 
dog  was  in  good  condition  when  taken  from  the  table. 

January  23. 

Death  occurred.  The  autopsy  revealed  that  the  loop  was  gan- 
grenous.   The  other  organs  were  normal. 


l62  SURGICAL  ANEMIA  AND  RESUSCITATION 

EXPERIMENT    23 
January  22,  1909. 

Mongrel  dog;  condition,  good.  Ether ;  morphia,  gr.  ^.  A  15  cm, 
loop,  midway  between  the  pylorus  and  cecum,  was  ligated.  At  the 
end  of  8  hours  and  40  minutes  the  tape  was  removed,  and  the  abdomen 
closed.    The  dog  was  taken  from  the  table  in  good  condition. 

January  23. 

Death  occurred  during  the  night.  Autopsy  showed  the  loop  to 
be  gangrenous.     The  other  organs  were  negative. 

EXPERIMENT    24 

January  14,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  }4-  A  15  cm. 
loop,  about  60  cm.  from  the  cecum,  was  ligated.  At  the  end  of 
p  hours  the  tape  was  removed,  and  the  abdomen  closed. 

January  15. 

The  dog  was  found  dead.  At  autopsy  the  loop  was  found  to  be 
gangrenous,  but  the  other  organs  were  normal. 

Group  II 

Experiments  in  Which  a  Loop  of  Small  Intestine  Was  Li- 
gated, a  Lateral  Anastomosis  Having  Been  Previously 
Made  to  Isolate  the  Loop,  and  the  Tape  Removed 
Before  Closing  the  Abdomen 

EXPERIMENT    25 

February  2,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  J4-  A  lateral 
anastomosis  was  made  about  30  cm.  from  the  pylorus.  A  15  cm. 
loop  external  to  the  anastomosis  was  ligated.  At  the  end  of  7  hours 
the  tape  was  removed,  and  the  abdomen  closed.  The  dog  died  in  a 
short  time  after  this.    The  autopsy  showed  the  loop  to  be  gangrenous. 

EXPERIMENT    26 

February  i,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  }^.  A  lat- 
eral intestinal  anastomosis  was  made  about  60  cm.  from  the  cecum. 
A  loop  of  intestine  (length  not  stated)  external  to  the  anastomosis 
was  ligated.     At  the  end  of  8  hours  the  tape  was  removed,  and  the 


ANEMIA  OF  THE  SMALL  INTESTINE  163 

abdomen  closed.     The  dog  was  in  good  condition  at  the  end  of  the 
operation. 

February  2. 

The  dog  was  still  alive,  but  very  weak.  The  bowels  moved,  and 
there  was  no  vomiting.  Temperature,  40.8°  C. ;  pulse,  150,  and 
very  weak.  Death  occurred  during  the  afternoon.  At  the  autopsy 
free  fluid  was  found  in  the  peritoneal  cavity.  There  was  some  slough- 
ing around  the  sutures  in  the  abdominal  wall.  The  loop  was  in  a 
condition  bordering  on  gangrene. 


EXPERIMENT    27 

January  27,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gv.  %.  A  lat- 
eral intestinal  anastomosis  was  made  about  60  cm.  from  the  jejunum. 
A  15  cm.  loop,  external  to  the  anastomosis,  was  ligated  en  masse,  as 
in  the  experiments  in  Group  I.  At  the  end  of  8  hours  the  tape  was 
removed,  and  the  abdomen  closed.  The  color  of  the  loop  showed  at 
this  time  that  the  circulation  had  not  been  entirely  shut  off.  The 
dog  was  in  good  condition  at  the  end  of  the  operation, 

January  28. 

The  dog  was  very  weak,  with  a  subnormal  temperature,  and 
pulse  rate  of  180  per  minute.     The  bowels  moved. 

January  29. 

Death  occurred  during  the  evening,  under  appearances  of  ex- 
treme exhaustion.  For  the  last  forty-eight  hours  the  pulse  had  con- 
tinued to  be  abnormal.  At  the  otherwise  negative  autopsy  the  loop 
was  found  to  be  gangrenous. 

EXPERIMENT    28 

February  3,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  J4-  A  lat- 
eral intestinal  anastomosis  was  made  about  30  cm.  from  the  pylorus. 
A  20  cm.  loop,  external  to  the  anastomosis,  was  ligated.  At  the  end 
of  8  hours  the  tape  was  removed,  and  the  abdomen  closed. 

February  4. 

The  dog  was  greatly  prostrated.  The  temperature  was  subnor- 
mal, and  the  pulse  could  not  be  counted.  Death  occurred  at  about 
noon.  Except  for  the  fact  that  no  return  of  circulation  was  shown 
in  the  loop  the  autopsy  was  negative. 


i64  SURGICAL  ANEMIA  AND  RESUSCITATION 

EXPERIMENT    29 

February  4,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  A  lat- 
eral intestinal  anastomosis  was  made  about  90  cm.  from  the  jejunum. 
A  20  cm.  loop,  external  to  the  anastomosis,  was  ligated.  At  the  end 
of  8  hours  the  tape  was  removed  and  the  abdomen  closed.  The 
dog  was  in  good  condition  when  taken  from  the  table. 

February  5. 

Death  occurred  during  the  night.  The  loop  was  gangrenous,  but 
otherwise  the  autopsy  was'  negative. 


Group  III 

Experiments  in  Which  a  Lateral  Anastomosis  Was  Made,  a 

Loop  of  Intestine  Ligated,  and  the  Tape  Left  in 

Place  After  the  Abdomen  Was  Closed 

EXPERIMENT    30 

February  16,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  34-  A  lat- 
eral anastomosis  was  made  about  30  cm.  from  the  jejunum.  A  20  cm. 
loop,  external  to  the  anastomosis,  was  ligated  with  tape,  in  the  usual 
way,  and  the  tape  left  in  place  when  the  abdomen  was  closed. 

February  17. 

Death  occurred  during  the  night,  about  18  hours  after  the  opera- 
tion.    Except  for  gangrene  of  the  loop  the  autopsy  was  negative. 


EXPERIMENT    31 

February  22,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  A  lat- 
eral anastomosis  was  made  about  90  cm.  from  the  cecum.  A  15  cm. 
loop,  external  to  the  anastomosis,  was  ligated,  and  the  tape  left  in 
place  when  the  abdomen  was  closed.  The  dog  made  a  good  recovery 
from  the  anesthetic,  but  in  the  afternoon  his  temperature  ran  up  to 
38.3°.  He  became  progressively  weaker,  and  died  during  the  night, 
about  18  hours  after  the  operation.  The  autopsy  revealed  gangrene 
of  the  loop,  but  was  otherwise  negative. 


ANEMIA  OF  THE  SMALL  INTESTINE]  165 

EXPERIMENT    32 
March  8,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  ^.  A  lat- 
eral anastomosis  was  made,  about  90  cm.  from  the  pylorus,  leaving  a 
loop  external  to  it  of  30  cm.  Twenty-five  centimeters  of  this  loop 
were  ligated,  the  tape  allowed  to  remain  in  place,  and  the  abdomen 
closed.  The  temperature  immediately  after  the  operation  was  37.8°, 
while  four  hours  later  it  had  fallen  to  36.1°  C.  The  dog  grew  pro- 
gressively weaker,  and  died  during  the  night,  about  18  hours  after 
the  operation.  The  autopsy  was  negative  except  for  revealing  that 
the  loop  was  gangrenous. 


EXPERIMENT    33 
March  10,  1909. 

Mongrel  bitch;  condition,  good.  Ether;  morphia,  gr.  ^.  Tem- 
perature before  the  operation,  37.8°  C. ;  pulse,  80  per  minute.  A  lat- 
eral anastomosis  was  made,  about  90  cm.  from  the  jejunum,  leaving 
a  30  cm.  loop  external  to  it.  Fifteen  centimeters  of  this  loop  were 
ligated,  the  tape  allowed  to  remain  in  place,  and  the  abdomen  closed. 
Progressive  weakness  followed  the  operation,  the  temperature  falling 
to  36.2°,  while  the  pulse  grew  weaker  and  more  and  more  rapid. 

March  ii. 

Death  occurred  during  the  night,  about  18  hours  after  the  opera- 
tion. The  loop  was  gangrenous.  Otherwise  the  autopsy  was  neg- 
ative. 

EXPERIMENT    34 

March  5,  1909. 

Hound  bitch;  condition,  good.  Ether;  morphia,  gr.  J4-  A  lateral 
anastomosis  was  made,  about  60  cm.  from  the  pylorus,  leaving  a  loop 
outside  of  the  anastomosis  which  was  30  cm.  long.  Fifteen  centi- 
meters of  this  loop  were  ligated,  the  tape  being  left  in  place  when  the 
abdomen  was  closed.  Throughout  the  afternoon  the  bitch  was  in  a 
state  of  profound  prostration,  the  temperature  gradually  falling  to 
36.1°,  and  the  pulse  becoming  weaker  and  weaker.  There  was  no 
vomiting.     The  bowels  moved  in  a  normal  way. 

March  6. 

Death  occurred  at  5:00  p.m.,  about  30  hours  after  the  operation. 
Except  for  the  loop  being  gangrenous  the  autopsy  was  negative. 


l66  SURGICAL  ANEMIA  AND  RESUSCITATION 

Group  IV 

Experiments  in  Which  a  Lateral  Anastomosis  Was  Made,  a 

Loop  of  Intestine  Ligated,  and  the  Loop  Excised  at 

the  End  of  the  Period  of  Anemia  Before 

Closing  the  Abdomen 

EXPERIMENT    35 
December  12,  1910. 

Mongrel  dog;  weight,  11  kilos;  condition,  good.  Ether;  morphia, 
gv.  %.  A  lateral  anastomosis  was  made,  isolating  a  loop  of  small  in- 
testine near  the  ileocecal  valve.  Fifteen  centimeters  of  this  loop  were 
ligated,  and  the  abdomen  closed.  At  the  end  of  7  hours  the  abdomen 
was  reopened,  and  the  anemic  loop  excised,  the  open  ends  of  ileum 
being  inverted  with  a  purse-string  suture.  The  loop  removed  was 
dark  purple.    The  recovery  was  good. 

December  13. 

Temperature,  41.1°  C.     The  dog  was  very  stupid. 

December  14. 

Temperature,  38.9°;  pulse,  132;  respiration,  24.  The  dog  moved 
about  and  ate. 

December  15. 

Temperature,  38.9°;  pulse,  112;  respiration,  22. 

December  16. 

Temperature,  38.9° ;  pulse,  128 ;  respiration,  22.  The  dog  was 
very  sick;  had  diarrhea,  and  urinated  on  his  bandages. 

December  20. 

Steady  improvement  up  to  this  date.  Priapism  was  constantly 
present. 

December  30. 

Complete  recovery. 

EXPERIMENT    36 

December  13,  1910. 

Mongrel  bitch;  weight,  12  kilos;  condition,  good.  Ether;  mor- 
phia, gr.  J4-  The  details  of  this  experiment  were  the  same  as  in  the 
two  preceding  experiments  in  this  group,  30  cm.  of  ileum  being 
ligated,  replaced  in  the  abdomen,  and  removed  at  the  end  of  7  hours. 
The  operative  recovery  was  good,  and  the  bitch  progressed  favorably 


ANEMIA  OF  THE  SMALL  INTESTINE  1 67 

until    the    sixth    day,    when    she    was    found    dead   and    stiff    in    the 

morning. 

Autopsy. — General  peritonitis  was  present.  The  intestinal  anas- 
tomosis was  patent,  and  in  good  condition.  An  abscess  in  the  pelvis 
had  ruptured.     Death  was  due  to  infection  from  this  cause. 

EXPERIMENT    37 

December  23,  1910. 

Mongrel  dog;  weight,  14  kilos;  condition,  good.  This  was  a 
recovery  dog  from  one  of  the  intestinal  injection  experiments.  Ether; 
morphia,  gr.  J4.  Twenty  centimeters  of  the  loop  isolated  by  the 
enteroenterostomy  were  ligated,  replaced  in  the  abdomen,  and  left 
there  for  yYi  hours.  At  the  end  of  this  time  the  loop  was  excised; 
the  operative  recovery  was  good. 

December  30. 

The  dog  had  never  been  seriously  ill  up  to  this  date.  The  wound 
in  the  abdomen  was  almost  closed,  and  recovery  was  practically  com- 
plete. 

EXPERIMENT    38 
March  8,  1909. 

Mongrel  dog;  condition,  good.  Ether;  morphia,  gr.  34.  A  lat- 
eral anastomosis  was  made  about  120  cm.  from  the  jejunum,  leaving 
a  30  cm.  loop  external  to  it.  Twenty  centimeters  of  this  loop  were 
ligated  in  the  usual  way,  and  the  tape  left  in  place  for  5  hours.  At 
the  end  of  this  time  all  of  the  ischemic  tissue  was  excised,  the  ends 
of  the  intestine  being  closed  with  purse-string  sutures,  and  inverted. 
The  dog  was  in  good  condition  when  removed  from  the  table. 

March  9. 

Death  occurred  during  the  night.     The  autopsy  was  negative. 

EXPERIMENT    39 

December  14,  1910. 

Mongrel  dog;  weight,  9.5  kilos;  condition,  good.  Ether;  morphia, 
gr.  ^.  On  the  first  day  the  enteroenterostomy  was  performed  at 
10:00  p.m.,  and  the  loop  of  ileum  ligated,  30  cm.  being  occluded. 
The  next  morning,  at  the  end  of  10  hours,  the  dog  was  etherized 
again,  in  order  to  open  the  abdomen  and  remove  the  loop,  and  died 
from  the  anesthetic.  The  loop  was  gray,  the  abdomen  filled  with  very 
foul  free  fluid,  and  above  the  loop  the  intestine  was  ballooned. 


l68  SURdlCAL  ANEMIA  AND  RESUSCITATION 

Group  V 

Experiments  in  Which  a  Lateral  Anastomosis  Was  Made,  a 

Loop  of  Intestine  Ligated,  a  Drainage  Tube 

Inserted  Into  the  Loop,  and  the 

Abdomen  Closed 

EXPERIMENT    40 
March  4,  19 10. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  A  lateral  anastomosis  was 
made  in  the  usual  way.  A  25  cm.  loop  of  jejunum,  external  to  the 
anastomosis,  was  ligated.  Into  the  loop  a  rubber  drainage  tube  was 
inserted,  and  the  operative  field  dammed  as  much  as  possible  with 
omentum.  The  abdomen  was  then  closed,  except  for  the  place 
through  which  the  tube  passed,  the  tape  being  left  in  place. 

March  5. 

Death  occurred  during  the  night,  about  18  hours  after  the  opera- 
tion. At  the  autopsy  it  was  found  that  the  tape  had  slipped,  and  that 
general  peritonitis  had  set  in.  The  loop  was  gangrenous,  and  there 
must  have  been  absorption  of  toxic  material  from  it. 

EXPERIMENT    41 
March  31,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  An  anastomosis  was  made, 
which  isolated  90  cm.  of  jejunum.  The  entire  loop  was  ligated,  and 
drained  with  a  rubber  tube.  The  abdomen  was  closed,  leaving  a 
gauze  dam  and  the  tape  in  place.  At  the  close  of  the  operation  the 
dog  was  in  good  condition.  During  the  afternoon  the  dog  became 
very  much  prostrated.  The  temperature  at  6  :oo  p.  m.  was  35.8°  C. ; 
the  pulse,  180. 

April  i. 

The  dog  was  found  dead  about  18  hours  after  the  operation.  The 
autopsy  showed  gangrene  of  the  loop,  but  otherwise  was  negative. 

EXPERIMENT    42 

April  ii,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.    Ether.    An  anastomosis  was  made, 


ANEMIA  OF  THE  SMALL  INTESTINE  169 

which  isolated  90  cm.  of  jejunum.  The  entire  loop  was  ligated,  the 
drainage  tube  inserted  into  it,  and  the  field  dammed  with  gauze.  The 
abdomen  was  closed.  At  the  close  of  the  operation  the  dog  was  in 
good  condition.  At  6:00  p.  m.  the  dog  was  much  prostrated,  with  a 
temperature  of  35.8°  C.    and  pulse  of  160. 

April  12. 

The  dog  was  very  sick.  Profound  toxemia  was  evidently  pres- 
ent. Death  occurred  at  12:00  m.,  almost  2y  hours  after  the  operation. 
Just  before  death  the  temperature  was  35.0°  and  the  pulse  190.  The 
dog  had  been  vomiting  for  some  time.  At  the  autopsy  the  only 
change  found  was  the  gangrenous  loop. 

EXPERIMENT    43 
April  6,  19 10. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  An  anastomosis  was  made, 
which  isolated  about  90  cm.  of  the  jejunum.  This  loop  was  ligated, 
and  the  rubber  drainage  tube  inserted  in  the  usual  way,  a  gauze  dam 
being  placed  around  the  field  of  operation.  The  abdomen  was  then 
closed.  At  6  :oo  p.  m.  the  dog  was  greatly  prostrated,  and  vomited 
freely,  although  he  had  been  in  good  condition  at  the  close  of  the 
operation.    Temperature,  38.9° ;  pulse,  190. 

April  7. 

The  dog  was  still  greatly  prostrated,  vomited  freely,  and  seemed 
to  be  dying.  The  wound  was  opened,  and  as  much  of  the  gangren- 
ous bowel  removed  as  could  be  done  without  disturbing  the  dam. 
Temperature,  36.1°;  pulse,  180.  Death  occurred  during  the  after- 
noon, about  30  hours  after  the  operation.  At  the  autopsy  nothing 
abnormal  was  found  but  the  gangrenous  loop.  There  was  no  peri- 
tonitis. 

EXPERIMENT    44 

March  8,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  Operative  procedures  ex- 
actly as  in  Experiment  40,  a  25  cm.  loop  external  to  the  anastomosis 
being  ligated  and  drained  with  the  rubber  tube.  At  the  close  of  the 
operation  the  dog  was  in  good  condition. 

March  8. 

The  dog  was  vomiting,  and  very  sick.  The  prostration  was  ex- 
treme. The  bowels  had  not  moved.  Temperature,  36.3°  C. ;  pulse, 
160.     There    was   considerable   discharge    from   the    drainage   tube. 


I70  SURGICAL  ANEMIA  AND  RESUSCITATION 

Later  in  the  day  the  general  temperature  seemed  to  be  somewhat  im- 
proved, although  the  temperature  was  still  subnormal,  and  the  pulse 
rapid  and  feeble. 

March  9. 

General  condition,  about  the  same.     Temperature,  35.8°. 

March  10. 

There  was  less  vomiting,  and  the  bowels  had  moved  during  the 
night.  The  degree  of  prostration  was  about  the  same.  There  was 
no  abdominal  distention.  The  discharge  from  the  tube  was  very 
foul.  This  discharge,  when  collected  and  injected  into  another  dog, 
produced  about  the  same  symptoms  that  were  later  obtained  from 
injecting  intestinal  extract,  but  the  dose  was  too  small  to  cause 
death. 

March  ii. 

General  condition  somewhat  improved,  but  the  prostration  was 
still  extreme.  Temperature,  36.3° ;  pulse,  145.  The  vomiting  had 
ceased,  but  profuse  diarrhea  had  begun.  Large  amounts  of  water 
had  been  drunk,  but  no  food  taken  since  the  beginning  of  the  experi- 
ment.    The  discharge  from  the  loop  was  still  very  profuse  and  foul. 

March  12. 

General  condition  much  improved,  and  prostration  much  less 
marked.  Food  was  still  refused.  The  diarrhea  persisted.  Tempera- 
ture, 38.9° ;  pulse,  120.     Nose  dry.     Eyes  glazed. 

March  13. 

The  dog  was  found  dead  in  the  morning,  about  5  days  after 
the  operation.  The  autopsy  showed  that  the  entire  ischemic  loop 
had  sloughed  away.  About  the  site  of  the  operation  general  peritoni- 
tis had  developed.  The  anastomosis  had  separated,  but  whether  this 
was  a  result  of  imperfection  of  technique,  and,  hence,  the  cause  of 
the  peritonitis,  could  not  be  made  out.  The  spleen  was  large  and 
soft.  The  liver  was  abscessed,  and  in  general  showed  the  effects  of 
toxemia.  Sections  from  the  kidneys  showed  acute  nephritis.  The 
intestines  showed  the  presence  of  enteritis. 

EXPERIMENT    45 

March  14,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  An  anastomosis  was  made, 
which  isolated  a  loop  of  intestine  90  cm.  long,  the  portion  selected 
being  part  of  the  jejunum.     A  30  cm.  loop,  external  to  the  anas- 


ANEMIA  OF  THE  SMALL  INTESTINE  171 

tomosis,  was  ligated.  Into  the  loop  a  rubber  tube  was  inserted  for 
drainage,  and  the  operative  field  dammed  off  as  much  as  possible 
with  gauze.  The  abdomen  was  then  closed,  the  tape  and  gauze  being 
left  in  place.  At  the  close  of  the  operation  the  dog  was  in  good 
condition. 

March  15. 

The  dog  was  greatly  prostrated,  with  a  temperature  of  36.1° 
and  pulse  of  160.  There  had  been  no  vomiting  or  diarrhea.  All 
nourishment  and  water  were  refused.  The  discharge  from  the  drain- 
age tube  was  very  foul  and  profuse. 

March  16. 

General  condition  about  the  same,  except  that  the  dog  had 
vomited  throughout  the  night,  and  had  profuse  diarrhea.  Some 
water  was  taken,  but  food  was  refused.  Temperature,  37.5°;  pulse, 
150. 

March  17. 

The  prostration  was  less  marked,  but  the  vomiting  and  diarrhea 
were  profuse.  The  discharge  from  the  tube  was  still  profuse  and 
very  foul.  Large  quantities  of  water  were  drunk,  but  all  food  was 
refused. 

March  19. 

The  dog  seemed  to  be  much  better.  Temperature,  38.3° ;  pulse, 
120.  For  the  first  time  since  the  operation  a  little  food  was  eaten. 
The  vomiting  and  diarrhea  had  about  ceased.  From  the  drainage 
tube  and  from  the  gauze  around  it  there  was  still  considerable  dis- 
charge. 

March  21. 

Condition  much  improved.  Food  was  well  taken.  The  rubber 
drainage  tube  came  out  in  the  morning,  and  with  it  a  large  amount 
of  pus  and  necrotic  material,  but  the  gauze  stayed  in  place.  Tem- 
perature, 37.8°;  pulse,  105. 

March  24. 

Food  was  taken  with  evident  relish.  The  discharge  was  very 
profuse.    The  gauze  was  removed.     Temperature,  37.8° ;  pulse,  95. 

March  28. 

For  a  week  the  dog  had  seemed  to  be  free  from  all  complica- 
tions. The  discharge  still  persisted,  but  for  the  last  three  days  the 
temperature  had  been  normal.  The  dog  was  chloroformed  (10  days 
after  the  operation),  and  at  the  autopsy  there  was  found  to  be  perito- 


172  SURGICAL  ANEMIA  AND  RESUSCITATION 

nitis  localized  about  the  site  of  the  operation.  It  was  well  walled  off 
with  adhesions.  The  entire  ischemic  loop  had  sloughed  away.  One 
end  of  the  loop  was  like  a  fibrous  cord,  while  the  other  was  simply 
closed.  There  did  not  seem  to  be  any  other  changes  in  the  abdominal 
organs.  Sections  were  taken  from  the  liver,  spleen,  and  intestines, 
but  these  did  not  show  any  microscopic  changes  of  consequence. 


Group  VI 

Experiments  in  Which  a  Lateral  Anastomosis  Was  Made,  a 

Loop  of  Intestine  Ligated,  and  the  Loop  Allowed 

to  Project  Through  the  Abdominal  Wound. 

EXPERIMENT    46 
April  23,  1910. 

Mongrel  dog;  condition,  good.  A  laxative  was  given  twenty- 
four  hours  before  the  operation.  Ether.  An  anastomosis  was  made, 
isolating  about  60  cm.  of  the  ileum.  Part  of  the  loop  thus  made  was 
ligated  and  the  bowel  opened.  Then,  instead  of  putting  in  a  drain- 
age tube,  and  leaving  the  ischemic  portion  inside  of  the  abdomen,  it 
was  withdrawn,  and  the  abdomen  closed  around  it.  The  dressings 
were  applied  around  it.  At  the  close  of  the  operation  the  dog  was 
in  good  condition.  At  6  :oo  p.  M.  there  had  been  no  symptoms  of 
toxemia. 

April  24. 

On  the  whole  the  condition  of  the  dog  was  good  and  in  marked 
contrast  to  that  of  the  dogs  in  other  experiments  in  which  the 
ischemic  loop  was  left  in  the  abdomen.  Temperature,  36.7°  C. ;  pulse, 
108.  The  wound  was  very  foul,  and  the  intestine  had  almost  com- 
pletely sloughed  away  24  hours  after  the  operation.  There  was  con- 
siderable diarrhea,  and  there  had  been  some  vomiting  during  the 
night. 

April  25. 

General  condition  very  good.  Most  of  the  loop  had  sloughed 
off,  and  there  was  some  localized  infection.  The  edges  of  the  wound 
were  separated  a  little,  and  the  pus  allowed  to  escape.  Tempera- 
ture, 38.9° ;  pulse,  120.  There  was  still  profuse  diarrhea,  but  no 
vomiting.     Large  quantities  of  water  were  taken,  but  no  food. 


ANEMIA  OF  THE  SMALL  INTESTINE  173 

April  26. 

The  diarrhea  still  persisted,  and  the  amount  of  discharge  from 
the  wound  had  increased.     Temperature  and  pulse  the  same. 

April  27. 

Condition  about  the  same.     Temperature,  38.9°;  pulse,  115. 

May  2. 

The  dog  seemed  to  be  in  good  condition,  running  around  the 
kennel  and  eating  well.  Temperature,  normal.  There  was  still  some 
discharge  from  the  incision,  but  the  intestine  had  sloughed  entirely 
away. 

May  id. 

The  dog  was  chloroformed.  At  the  autopsy  a  localized  abscess 
and  peritonitis  were  found  near  the  wound,  but  otherwise  the  autopsy 
was  negative.  There  had  been  no  involvement  of  kidneys,  liver,  or 
spleen. 

EXPERIMENT    47 

December  21,  1910. 

Mongrel  dog;  weight,  16  kilos;  condition,  good.  Ether.  Thirty 
centimeters  of  small  intestine  were  ligated  and  left  outside  the  abdo- 
men, an  enteroenterostomy  having  been  previously  made  to  isolate 
the  loop.    The  operative  recovery  was  good. 

December  22. 

The  loop  was  black  and  mushy.  It  was  cut  away  level  with 
the  wound  in  the  abdominal  wall  24  hours  after  the  ligation.  At 
9:00  A.M.  the  temperature  was  40.0°  C,  the  pulse  160,  and  the  res- 
pirations 28.  At  4:30  P.M.  the  temperature  was  38.9°,  the  pulse  108, 
and  the  respiration  20.    Respiration  was  carried  on  with  difificulty. 

December  22,  23,  and  24. 

The  temperature  averaged  41.1°,  and  the  dog  was  very  ill. 

December  30. 

A  fecal  fistula  was  present.  The  appetite  was  good,  the  dog 
drank  freely.  Weight  as  at  beginning  of  experiment,  10  kilos.  The 
dog  was  killed  with  chloroform. 

Autopsy. — There  was  no  evidence  of  peritonitis.  The  entero- 
enterostomy was  patent,  and  feces  were  in  the  cecum. 


174  SURGICAL  ANEMIA  AND  RESUSCITATION 


Group  VII 

Experiments  in  Which  There  Was  Partial  Occlusion  of  the 

^Blood  Supply  of  a  Loop  of  Intestine  by  Ligation 

of  the  Corresponding  Arteries  and  Veins 

in  the  Mesentery 

EXPERIMENT    48 
May  16,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  The  blood-vessels  supply- 
ing 90  cm.  of  intestine  were  ligated,  and  the  abdomen  closed. 

May  17. 

The  dog  was  found  dead,  death  having  occurred  about  18  hours 
after  the  ligation.  The  autopsy  revealed  that  the  entire  portion  of 
the  intestine,  the  vessels  of  which  were  ligated,  was  gangrenous. 
Otherwise  the  autopsy  was  negative. 

EXPERIMENT    49 

December  19,  1910. 

Mongrel  dog;  weight,  5  kilos;  condition,  good.  Ether.  Three 
main  branches  of  arteries  and  veins  supplying  the  terminal  portion 
of  the  ileum  were  ligated,  shutting  off  the  blood  supply  of  15  centi- 
meters of  gut.  The  isolated  portion  at  once  became  anemic  and  con- 
tracted.    After  a  few  hours  fever  developed,  which  persisted. 

December  22. 

Death  occurred  at  1 130  p.  M.^  about  31  hours  after  the  ligation. 
Three  centimeters  of  the  anemic  gut  were  gangrenous  and  perforated. 
General  peritonitis  was  present.  Above  the  anemic  area  the  gut  was 
constricted. 

EXPERIMENT    50 

December  17,  1910. 

Mongrel  dog;  weight,  10  kilos;  condition,  good.  Ether.  Four 
main  branches  of  arteries  and  veins  supplying  20  cm.  of  the  terminal 
portion  of  the  ileum  were  ligated. 

December  18. 

Temperature,  39.4°  C;  respiration,  20;  pulse,  160.  General  con- 
dition, poor. 


ANEMIA  OF  THE  SMALL  INTESTINE  175 

December  19. 

Death  occurred  at  6  :oo  a.  m.^  about  44  hours  after  the  ligation. 
The  autopsy  revealed  the  presence  of  free  bloody  fluid  in  the  abdomi- 
nal cavity,  general  peritonitis,  gangrene  of  the  loop  of  ileum,  and 
distention  of  the  intestines  above  the  latter.  The  duodenum  was 
more  distended  than  the  rest  of  the  small  intestine.  Eight  centi- 
meters above  the  place  vi^here  the  gangrene  began  the  small  intestine 
w^as  intussuscepted  for  6  cm. 

EXPERIMENT    51 
April  19,  1910. 

Mongrel  dog;  condition,  good.  A  cathartic  was  given  twenty- 
four  hours  before  the  operation.  Ether.  Blood  vessels  were  ligated 
in  the  same  way,  and  the  abdomen  closed.  The  affected  25  cm.  of 
the  intestine  was  bloodless  at  the  end  of  the  operation. 

April  20. 

The  dog  had  a  good  appetite,  and  seemed  to  be  in  good  condi- 
tion. In  his  food  was  placed  a  large  amount  of  lampblack,  the  mix- 
ture being  given  by  means  of  a  stomach  tube. 

April  21. 

Except  for  profuse  diarrhea  and  vomiting  the  condition  was 
good.  Under  ether  anesthesia  the  abdomen  was  reopened,  two  days 
after  the  ligation,  and  a  portion  of  the  normal  as  well  as  of  the 
ischemic  intestine  removed.  It  was  found  that  the  normal  lacteals 
had  taken  up  the  lampblack,  while  the  ischemic  lacteals  had  not. 
Staining  the  sections  for  bacteria  showed  that  the  latter  had  been 
made  more  vulnerable  to  taking  up  bacteria,  that  they  had  passed 
through  the  tunica  serosa,  and  that  around  the  intestine  there  was 
localized  peritonitis.  There  had  also  been  extensive  epithelial 
desquamation.  The  blood  vessels  showed  extensive  sclerosis,  and 
the  tissues  generally  were  very  edematous.  The  lumina  of  the  glands 
were  filled  with  desquamated  cells.     The  dog  recovered. 

EXPERIMENT    52 

April  18,  1910. 

Black  and  tan  dog;  condition,  good.  A  cathartic  was  given 
twenty-four  hours  before  the  operation.  Ether.  At  the  junction 
of  the  duodenum  and  jejunum  several  blood  vessels  were  ligated  in 
the  mesentery.  By  this  means  a  25  cm.  loop  of  intestine  was  ap- 
parently deprived  of  its  blood  supply.  The  abdomen  was  closed  in 
the  usual  way,  and  the  dog  allowed  to  recover. 


176  SURGIC-\L  AXEMIA  AND  RESUSCITATION 

April  19. 

The  dog  was  in  good  condition,  and  showed  no  symptoms  at- 
tributable to  the  ligation. 

April  28. 

All  the  time  during  the  past  ten  days  the  dog  had  been  in  good 
condition,  and  had  shown  no  symptoms  of  any  sort.  Under  ether 
anesthesia  the  abdomen  was  reopened,  and  a  portion  of  the  ischemic 
loop  resected.  Sections  made  from  this  portion  showed  that  certain 
areas  were  necrotic.  Throughout  there  had  been  great  desquama- 
tion of  the  epithelium  of  the  lumen  of  the  intestine,  accompanied  by 
some  hemorrhage  into  the  tissues.  For  the  greater  part  the  sections 
stained  poorly,  and,  in  some  areas,  amyloid  changes  could  be  demon- 
strated. The  tissue,  as  a  whole,  was  very  edematous,  and  structural 
details  could  not  be  made  out  clearly. 


Group  VIII 
Control  Experiment 

EXPERIMENT    53 

February  24,  1909. 

Fox  terrier  dog;  condition,  fair.  Ether;  morphia,  gr.  54-  As  a 
control  for  the  other  experiments  the  abdomen  was  opened  and  a 
lateral  anastomosis  made.  Xo  loop  of  intestine  was  ligated.  The 
abdomen  was  closed  in  the  usual  way.  The  dog  made  an  uninter- 
rupted recovery. 

Note. — Xo  more  control  experiments  were  done  at  this  time, 
because  a  wide  experience  in  doing  even  more  serious  opera- 
tions on  the  intestines  of  dogs  has  shown  that,  when  properly  done 
under  aseptic  precautions,  the  operative  side  alone  is  an  almost 
negligible  factor  in  affecting  the  results. 


ANEMIA  OF  THE  SMALL  INTESTINE 


177 


Tabulation  of  the  Experiments  on  Intestinal  Anemia 


Number 

Length  of 
Loop 

Duration  of 
Ligation 

Changes  in  Loop 

Duration  of  Life 

Group  1: 

I 

IS  cm- 

I  hour 

No  gross  changes 

IS  hours,  cause  of  death 
not  determined 

2 

IS  cm. 

I  hour 

No  gross  changes 

54  days,  chloroformed 

3 

30  cm. 

I  hour 

None,  adhesions 

55  days,  chloroformed 

4 
S 

IS  cm. 
17  cm. 

I  hour 

Complete  recovery 

2  hours 

Congestion,     perfora- 

6 days,  death  from  acute 

tion   near   ligation, 

peritonitis 

acute  peritonitis 

6 

IS  cm. 

2  hours 

None 

S4  days,  chloroformed 

7 

20  cm. 

2%  hours 

Congestion 

About  18  hours 

8 

2S  cm. 

3  hours 

None,  adhesions 

19  days 

9 

10  cm. 

4  hours 

No  gross  changes 

Short  time,  death  froai 
ether 

10 

IS  cm. 

4  hours 

No  gross  changes,  ad- 
hesions 

8  days 

II 

30  cm. 

S  hours 

Gangrene 

About  18  hours 

12 

15  cm. 

5  hours 

None,  adhesions 

7  days,  chloroformed 

13 

20  cm. 

6  hours 

Gangrene 

24  hours 

14 

20  cm. 

6  hours 

Partly  gangrenous 

About  18  hours 

IS 

IS  cm. 

6  hours 

Gangrene 

About  18  hours 

16 

IS  cm. 

6  hours 

Partly  gangrenous 

234  days 

17 

30  cm. 

6  hours 

Anemic 

J^  hour  after  operation 

18 

2S  cm. 

8  hours 

Gangrene 

About  30  hours 

19 

IS  cm. 

8  hours 

Gangrene 

About  18  hours 

20 

IS  cm. 

8  hours 

Gangrene 

About  18  hours 

21 

7  cm. 

8  hours 

Gangrene 

About  36  hours 

22 

IS  cm. 

8}4  hours 

Gangrene 

About  18  hours 

23 

IS  cm. 

8  hours,  40  mins. 

Gangrene 

About  18  hours 

24 

IS  cm. 

9  hours 

Gangrene 

About  1 8  hours 

Group  II: 

2S 

IS  cm. 

7  hours 

Gangrene 

Short  time  after  operation 

26 

8  hours 
8  hours 

Almost  gangrenous 
Gangrene 

About  30  hours 

% 

IS  cm. 

About  2J4  days 

20  cm. 

8  hours 

No  return  of  circula- 

Short time  after  operation 

tion 

29 

20  cm. 

8  hours 

Gangrene 

About  18  hours 

Group  III: 

30 

20  cm. 

(About  18  hours) 

Gangrene 

About  18  hours 

31 

IS  cm. 

(About  18  hours) 

Gangrene 

About  18  hours 

32 

25  cm. 

(About  1 8  hours) 

Gangrene 

About  18  hours 

33 

IS  cm. 

(About  18  hours) 

Gangrene 

About  18  hours 

34 

IS  cm. 

(About  30  hours) 

Gangrene 

About  30  hours 

Group  IV: 

35 

IS  cm. 

7  hours 

(loop  excised) 

Recovery 

36 

20  cm. 

7  hours 

(loop  excised) 

Death  on  6th  day,  due  to 
faulty  technique 

37 

20  cm. 

7H  hours 

(loop  excjsed) 

Recovery 

38 

20  cm. 

8  hours 

(loop  excised) 

About  18  hours 

39 

30  cm. 

10  hours 

(loop  excised) 

Lived  10  hours,  when 
death  was  caused  by 
second  etherization  for 
removal  of  the  loop 

Group  V : 

40 

2S  cm. 

About  18  hours 

Gangrene 

About  18  hours 

41 

90  cm. 

About  18  hours 

Gangrene 

About  18  hours 

42 

90  cm. 

About  27  hours 

Gangrene 

About  27  hours 

43 

90  cm. 

About  30  hours 

Gangrene 

About  30  hours 

44 

25  cm.. 

4  days 

Gangrene 

9  days 

45 

30  cm. 

14  days 

Gangrene,  sloughing 

Recovery 

Group  VI: 

46 

60  cm. 

1  day 

Sloughed  away 

Recovery 

47 

30  cm. 

I  day 

Gangrene,  cut  away 

Recovery 

178  SURGICAL  ANEMIA  AND  RESUSCITATION 

Tabulation  of  the  Experiments  on  Intestinal  Anemia — {Continued) 


Number 

Length  of 
Loop 

Duration  of 
Ligation 

Changes  in  Loop 

Duration  of  Life 

Group  VII: 
48 

49 

SO 
51 

52 

Group  VIII: 
S3 

Vessels  ligat- 

ed  in  go  cm. 

loop 
Vessels  ligat- 

edin  15  cm. 

loop 

Vessels  ligat- 

ed  in  20  cm. 

loop 
Vessels  ligat- 

ed  in  25  cm. 

loop 
Vessels  ligat- 

ed  in  25  cm. 

loop 

About  18  hours 
About  31  hours 

About  44  hours 
10  days 
10  days 

Gangrene 
Gangrene 

Gangrene 
Gangrene 
Gangrene 

About  18  hours 
About  31  hours 

About  44  hours 

Recovery  after  removal  of 
loop 

Recovery  after  removal  of 
loop 

Control    experiment,    re- 

covery 

Summary  of  Experiments  on  Intestinal  Anemia 

Group  I. — Intestine  ligation,  removal  of  ligature  before  closing  the 
abdomen. 

Number   of   experiments 24 

Duration   of   ligation i  to  9  hours 

Recoveries — dog    lived    one    week    or 

longer    7 

Deaths    17  (70-8%) 

Group  II. — Lateral  anastomosis,  ligation,  removal  of  ligature  before 

closing  abdomen. 

Number  of  experiments 5 

Duration   of    ligation 7  to  8  hours 

Recoveries — dog   lived    one    week    or 

longer   , o 

Deaths 5   (100%) 

Group  III. — Lateral  anastomosis,  ligation,  ligature  left  in  place. 

Number  of  experiments 5 

Duration  of  ligation 18  to  30  hours 

Recoveries — dog    lived    one    week    or 

longer  o 

Deaths    5   (100%) 


ANEMIA  OF  THE  SMALL  INTESTINE  179 

Group   IV. — Lateral   anastomosis,   ligation,   excision  of  loop   before 
closing  abdomen. 

Number  of  experiments 5 

Duration  of  ligation 7  to  10  hours 

Recoveries- — dog    lived    one    week    or 

longer   2 

Deaths   from    faulty  technique 2   (40%) 

Group  V. — Lateral  anastomosis,  ligation,  insertion  of  drainage  tube 
into  loop,  abdomen  closed. 

Number    of   experiments 6 

Duration  of  ligation 18  hrs.  to  14  days 

Recoveries — dog   lived   one    week   or 

longer 2 

Deaths   4  (66  2/3%) 

Group  VL — Lateral  anastomosis,  ligation  with  loop  made  to  project 
from  abdomen  until  it  sloughed  off. 

Number  of  experiments 2 

Duration  of  ligation I  to  2  days 

Recoveries — dog    lived    one    week    or 

longer 2 

Deaths    o  (0%) 

Group  VIL — Ligation  of  blood-vessels  supplying  a  loop  of  intestine. 

Number  of  experiments 5 

Duration  of  cessation  of  blood  supply  18  hrs.  to  10  days 

Recoveries — dog   lived    one    week    or 

longer     2  ^ 

Deaths    3  (60%) 

*  Part  of  the  gangrenous  loop  was  removed  for  microscopical  examination. 

THE  INJECTION  INTO  THE    INTESTINAL  TRACT    AND 

PERITONEAL  CAVITY  OF  DOGS  OF  JUICE  FROM 

LOOPS  OF  SMALL  INTESTINE  PREVIOUSLY 

RENDERED  ISCHEMIC  FOR  VARYING 

PERIODS  OF  TIME 

In  this  series  of  experiments,  the  natural  corollary  of  the 
preceding  series,  loops  of  the  small  intestine  of  dogs  were  de- 
prived of  their  circulation,  usually  for  eight  hours,  by  the 
usual  method  of  ligation.    The  loops  were  then  removed,  care- 


l8o  SURGIC\L  ANEMLA.  AND  RESUSCITATION 

fully  washed,  and  ptaced  in  a  mild  antiseptic  solution  to  kill 
bacteria  in  the  intestinal  tract,  washed  again  in  normal  saline 
solution,  ground  up  with  sterile  sand,  filtered,  the  filtrate  di- 
luted if  necessary  with  sterile  normal  saline  solution,  and  the 
resulting  fluid  injected  as  stated  in  the  following  experiments. 
The  point  was  to  ascertain  the  effect  of  absorption  into  the 
peritoneal  cavity  of  wholly  or  partially  gangrenous  intestine 
with  its  bacteria  and  their  toxins. 


Group  I 

Injection  into  the  Peritoneal  Cavity 

EXPERIMENT    i 
February  4,  1909. 

Bulldog  bitch;  condition,  good.  Before  the  injection  her  tem- 
perature was  37.8°  C,  and  pulse  90  per  minute.  At  9:00  a.m.  10 
c.  c.  of  intestinal  extract,  prepared  as  stated  above,  were  in- 
jected into  the  peritoneal  cavity  under  aseptic  precautions.  By  noon 
the  bitch  was  very  sick,  her  temperature  having  risen  to  39.4°  C,  and 
her  pulse  to  140.  The  prostration  was  extreme.  Death  occurred  at 
3:00  P.M.J  6  hours  after  the  injection  was  given.  Just  before  death 
the  temperature  had  fallen  to  subnormal.  At  the  autopsy  the  perito- 
neum was  found  to  be  congested.  Otherwise  the  findings  were  nega- 
tive. 

EXPERIMENT    2 
March  9,  1909. 

Mongrel  dog;  condition,  good.  Under  ether  anesthesia  10  c.  c. 
of  intestinal  extract  were  injected  into  the  peritoneal  cav- 
ity. Pulse  and  temperature  previous  to  this  were  normal.  At 
9:00  a.m.  the  temperature  was  38.3°  C.  At  3:30  p.m.  the  dog  was 
very  weak,  with  a  temperature  of  39.4°  C.  There  was  some  vomiting, 
but  the  prostration  was  the  most  prominent  symptom.  Death  oc- 
curred at  5  130  p.  M.  The  autopsy  revealed  nothing  but  intense  con- 
gestion at  the  site  of  the  injection. 

EXPERIMENT    3 

October  27,  1909. 

Mongrel  dog;  weight,  4.9  kilos;  condition,  good.  Under  light 
ether  anesthesia  10  c.  c.  of  intestinal  extract  were  injected  into  the 


ANEMIA  OF  THE  SMALL  INTESTINE  i8l 

abdominal  cavity  at  5  :oo  p.  m.  At  this  time,  without  apparent  cause, 
the  temperature  was  38.3°  C.  Two  ho^rs  later  it  had  fallen  to  37.4°  C. 
Twelve  hours  after  the  injection  the  dog  was  found  dead,  having 
vomited  clear,  greenish  fluid  several  times  during  the  night,  and  also 
having  had  diarrhea. 

EXPERIMENT    4 

October  29,  1909. 

Mongrel  dog;  weight,  4.2  kilos;  condition,  poor.  The  thyroid 
gland  was  enlarged.  At  10 150  A.  M.  8  c.  c.  of  intestinal  extract  were 
injected  into  the  abdominal  cavity.  Temperature,  37.2°  C.  At  2:00 
P.M.  the  temperature  had  fallen  to  35.1°  C,  the  pulse  being  76  and 
the  respiration  16.  The  dog  was  very  sick  and  cold,  and  constantly 
shivered.  At  9  150  p.  m.  the  temperature  was  the  same,  the  pulse  96, 
and  the  respiration  32.  The  dog  died  at  3  :20  a.  m.,  i6}i  hours  after 
the  injection. 

EXPERIMENT    5 

November  5,  1909. 

Mongrel  dog;  condition,  poor.  Ether  for  5  minutes.  Tempera- 
ture, 38.6°  C. ;  pulse,  196;  respiration,  22.  At  9:00  p.m.  10  c.  c.  of  in- 
testinal extract  were  injected  intraperitoneally.  The  injection  had 
no  effect,  and  recovery  followed. 

EXPERIMENT    6 

December  14,  1910. 

Mongrel  dog;  weight,  11  kilos;  condition,  good.  At  10:30  a.m. 
20  c.  c.  of  intestinal  extract  were  injected  intraperitoneally.  A  slight 
fall  in  temperature  followed,  the  dog's  feet  became  cold,  and  he  was 
constantly  sick,  but  complete  recovery  followed,  the  last  note  being 
made  15  days  later. 

EXPERIMENT    7 

December  15,  1910. 

Beagle  dog;  weight,  9  kilos;  condition,  good.  Prolonged  etheri- 
zation. At  9:00  A.M.  10  c.  c.  of  intestinal  extract  were  injected  in- 
traperitoneally. At  10  130  the  temperature  was  36.0°  C,  the  pulse  y2, 
and  the  respiration  28.  At  6:15  p.m.  the  temperature  had  risen  to 
about  38.3°  C.  and  the  respiration  to  40.  The  dog  was  very  thirsty, 
drinking  ly^  quarts  of  water  at  one  time,  vomited,  and  had  constant 
priapism.  The  pulse  was  very  weak  and  uncountably  rapid.  Death 
occurred  at  about  12:00  midnight,  15  hours  after  the  injection. 

Autopsy. — Rigor  mortis  was  well  developed  10  hours  post  mor- 
tem. There  was  free  bloody  peritoneal  fluid,  no  adhesions  of  the  in- 
testines, although  the  surfaces  of  the  coils  were  dead  and  lusterless 


1 82  SURGICAL  ANEMIA  AND  RESUSCITATION 

in  appearance;  the  kidneys  .showed  punctate  ecchymoses,  with  pa- 
renchymatous degeneration,  the  liver  the  same,  and  the  heart  had 
stopped  in  systole.  The  brain  was  softer  than  normal,  and  showed 
punctate  hemorrhages. 

EXPERIMENT    8 
December  15,  1910. 

Mongrel  dog;  weight,  14  kilos;  condition,  good.  Ether.  Twenty 
c.  c.  of  intestinal  extract  were  injected  intraperitoneally  at  11:00 
A.  M.  While  the  dog  was  more  or  less  prostrated  temporarily  re- 
covery was  complete  at  the  end  of  9  days. 

EXPERIMENT    9 

December  15,  1910. 

Mongrel  dog ;  weight,  7  kilos ;  condition,  good.  Ether.  At 
9:30  A.  M.  10  c.  c.  of  intestinal  extract  were  injected  intraperitoneally. 
There  was  a  rise  of  temperature,  pulse,  and  respiration.  The  dog  be- 
came ill,  with  cold  extremities,  great  thirst,  and  sudden  starting  on 
being  touched,  but  there  was  no  diarrhea  or  vomiting. 

December  16. 

Death  probably  occurred  at  about  4  :oo  a.  m.,  as  the  dog  was 
found  dead,  and  the  body  was  still  warm  at  10:00  a.  m. 

Autopsy. — Rigor  mortis  present.  The  intestines  were  matted  to- 
gether. The  brain  was  injected,  reddened  from  punctate  hemorrhages, 
and  softer  than  normal.  The  heart  had  stopped  in  systole,  the  lungs 
were  clear,  the  kidneys  showed  parenchymatous  degeneration  and  were 
swollen,  the  liver  showed  fatty  degeneration,  the  spleen  was  unaf- 
fected, and  there  was  free  fluid  in  the  peritoneal  cavity. 

EXPERIMENT    10 

December  15,  1910. 

Mongrel  dog;  weight,  7.5  kilos;  condition,  good.  Prolonged 
ether  anesthesia.  At  10  :oo  a.  m.  10  c.  c.  of  intestinal  extract  were 
injected  intraperitoneally.  The  temperature,  pulse,  and  respiration 
rose  markedly,  and  the  dog  was  very  ill,  but  by  6:15  p.  m.  his  condi- 
tion was  better  than  that  of  the  other  two  dogs  injected  at  the  same 
time.  Recovery  followed,  and  was  complete  15  days  later.  Two  out 
of  the  last  three  dogs  lived,  while  the  third  (Exp.  15)  died,  the  dog 
that  died  being  practically  the  same  weight  as  the  dog  in  this  experi- 
ment. 

EXPERIMENT    11 
December  22,  1910. 

Mongrel  bitch;  weight,  6  kilos;  condition,  good.  At  11:00  a.m. 
10  c.  c.  of  intestinal  extract  were  injected  intraperitoneally,  and  death 


ANEMIA  OF  THE  SMALL  INTESTINE  183 

occurred  probably  14  hours  later.  At  the  autopsy,  24  hours  after  the 
injection,  the  body  was  found  to  be  stiff,  the  viscera  were  all  in- 
jected, and  there  was  free  bloody  fluid  in  the  abdominal  cavity. 

EXPERIMENT    12 

January  16,  191 1. 

Mongrel  bitch  with  enlarged  thyroid  gland;  weight,  10  kilos;  con- 
dition, good.  At  9:30  A.  M.  10  c.  c.  of  intestinal  extract  were  injected 
intraperitoneally.  There  was  fever,  with  rise  of  pulse  and  respira- 
tion, but  no  vomiting  or  diarrhea.     Complete  recovery  followed. 

EXPERIMENT    13 

January  16,  191 1. 

Mongrel  dog;  weight,  9.5  kilos;  condition,  good.  At  9:45  A.M. 
10  c.  c.  of  intestinal  extract  were  injected  intraperitoneally.  At 
3:15  P.M.  the  stool  was  normal,  and  there  was  no  vomiting.  Later 
diarrhea  began.  The  general  condition  was  poor,  with  temperature 
of  38.9°  C,  pulse  of  80,  and  respiration  of  32. 

January  17. 

The  dog  was  found  dead  at  6 145  a.  m.^  21  hours  after  the  in- 
jection. 

EXPERIMENT    14 
January  25,  1910. 

Bulldog;  weight,  15.3  kilos;  condition,  good.  Ether;  morphia, 
gr.  Yi.  At  12:00  M.  17  c.  c.  of  intestinal  extract  were  injected  intra- 
peritoneally. Subsequently  in  -^y^  hours  the  temperature  fell  0.4°  C, 
the  pulse  24  beats,  and  the  respiration  rose  from  16  to  44  per  minute. 
Death  occurred  about  15  hours  later. 


Group  II 

Injection  into  the  Lumen  of  the  Intestine 

EXPERIMENT    15 

March  9,  1909. 

Mongrel  bitch;  condition,  good.  Under  ether  anesthesia  the 
abdomen  was  opened,  and  small,  frequently  repeated  doses  of  intes- 
tinal extract  were  injected  into  the  jejunum.  Ten  c.  c.  were  in- 
jected every  10  minutes,  until  60  c.  c.  in  all  had  been  given.  Six 
hours  later  the  bitch  showed  great  prostration,  with  vomiting  and 
diarrhea.     The  temperature  was  38.9°  C.    ' 


1 84  SURGICAL  ANEMIA  AND  RESUSCITATION 

March  io. 

Great  prostration  was  still  present,  as  well  as  the  vomiting  and 
diarrhea.    Temperature,  38.9°  C. 

March  ii. 

Condition,  better.     Temperature,  38.6°  C. 

March  14. 

Temperature,  37.8^  C.     Condition  continued  to  improve. 

EXPERIMENT    16 

March  10,  1909. 

Mongrel  dog;  condition,  good.  At  9:00  a.m.,  under  ether  anes- 
thesia, the  abdomen  was  opened,  and  20  c.  c.  of  intestinal  extract 
injected  into  the  duodenum.  By  noon  the  dog  had  recovered  from 
the  anesthetic,  but  was  greatly  prostrated.  The  temperature  was 
then  subnormal.  At  i  :oo  p.  M..  death  occurred,  apparently  from  ex- 
treme exhaustion. 

EXPERIMENT    17 

March  12,  1909. 

Mongrel  dog;  fcondition,  good.  Under  ether  anesthesia  30 
c.  c.  of  intestinal  extract  were  injected  into  the  jejunum.  By 
noon  the  dog  had  recovered  from  the  anesthetic,  but  was  in  poor  gen- 
eral condition.  He  vomited  frequently.  Temperature,  39.5°  C.  By 
5  :oo  p.  M.  the  condition  had  grown  worse.  There  was  beginning 
diarrhea,  and  the  vomiting  was  more  frequent.    Temperature,  40.0°  C. 

March  13. 

In  the  morning  the  dog  was  found  dead.  At  the  autopsy  the 
jejunum  was  found  to  be  congested.  For  120  cm.  below  the  point 
of  injection  it  looked  very  much  as  if  atony  of  the  bowel  had  been 
present,  owing  to  the  stasis  of  intestinal  contents.  Otherwise  the 
findings  were  negative. 

EXPERIMENT    18 

March  16,  1909. 

Mongrel  dog;  condition,  good.  Temperature,  before  operation, 
38.3°  C;  pulse,  100.  Under  ether  the  abdomen  was  opened  at 
9:00  a.m.,  and  10  c.  c.  of  intestinal  extract  were  injected  into 
the  jejunum.  By  noon  the  dog  had  recovered  from  the  anes- 
thetic, but  was  still  somewhat  prostrated.  There  was  no  vomiting 
or  diarrhea.     Temperature,  38.9°  C;  pulse,  no. 


ANEMIA  OF  THE  SMALL  INTESTINE  185 

March  17. 

There  was  some  diarrhea,  but  no  vomiting.  Temperature, 
39.4°  C. ;  pulse,  120. 

March  18. 

General  condition,  good.     Temperature,  38.3°  C. ;  pulse,  100. 

EXPERIMENT    19 

March  18,  1909. 

Mongrel  bitch ;  condition,  good.  Temperature,  before  operation, 
37.8°  C. ;  pulse,  100.  Under  ether  the  abdomen  was  opened,  and  300 
c.c.  of  intestinal  extract  were  injected  into  the  jejunum.  By  noon 
the  bitch  had  recovered  from  the  anesthetic,  but  her  condition  was 
poor,  and  growing  worse.    There  was  frequent  vomiting. 

March  19. 

There  was  less  frequent  vomiting,  but  profuse  diarrhea  and  great 
prostration.     Temperature,  38.9°  C. ;  pulse,  140. 

March  20.  ^ 

The  prostration  was  extreme,  but  there  was  still  less  vomiting. 
Temperature,  38.3°  C. ;  pulse,  130. 

March  21. 

Some  improvement  had  occurred.  There  was  no  diarrhea  or 
vomiting.     Temperature,  38.6°  C. ;  pulse,  130. 

March  22. 

The  bitch  was  very  much  better,  and  convalescing  rapidly. 

EXPERIMENT    20 

February  18,  1909. 

Mongrel  dog;  condition,  good.  Temperature,  before  injection, 
38.0°  C. ;  pulse,  90. 

9  :oo  A.  M. — Under  ether  anesthesia  20  c.  c.  of  intestinal  extract 
were  injected  into  the  duodenum,  just  below  the  pylorus,  the  abdo- 
men having  been  opened  under  careful  asepsis. 

12  :oo  M. — The  dog  was  vomiting,  and  had  profuse  diarrhea. 
Temperature,  40.0°  C. ;  pulse,  130. 

6  :oo  p.  M. — The  dog  was  very  ill  and  extremely  prostrated. 
Neither  vomiting  nor  diarrhea  was  as  severe  as  before.  Tempera- 
ture, 41.1°  C;  pulse,  140. 

February  19. 

In  the  morning  the  dog  was  still  greatly  prostrated,  but  was 
somewhat  better.     The  vomiting  had  stopped,  but  the  diarrhea  still 


1 86  SURGICAL  ANEMIA  AND  RESUSCITATION 

continued  actively.  Temperature,  40.0°  C. ;  pulse,  140.  At  6:00  p.m. 
the  condition  had  continued  to  improve.  The  temperature  had  fallen 
to  39.4°  C,  and  the  pulse  to  120. 

February  20. 

The  improvement  had  continued,  the  temperature  being  still 
lower.     Both  vomiting  and  diarrhea  had  ceased. 

February  25. 

The  dog  seemed  in  every  way  to  be  normal. 

EXPERIMENT    21 

February  23,  1909. 

Mongrel  dog ;  condition,  good.  Ether.  Ten  c.  c.  of  intestinal 
extract  were  injected  into  the  small  intestine,  as  in  the  preceding 
experiment.  Immediately  after  the  abdomen  was  closed  the  tempera- 
ture was  37.2°  C.  and  the  pulse  100. 

4:09  P.M. — The  dog  had  recovered  from  the  ether,  but  was  very 
sick.     He  vomited  occasionally.     Temperattire,  37.8°  C. ;  pulse,   120. 

5  :oo  p.  M. — The  condition  was  growing  worse.  Occasional  vomit- 
ing and  some  diarrhea.    Temperature,  38.5°  C. 

February  24. 

The  dog  was  extremely  prostrated.  There  was  profuse  diarrhea 
and  some  vomiting.    Temperature,  39.6°  C. ;  pulse,  140. 

February  26. 

While  some  infection  of  the  abdominal  wound  was  present  the 
dog  was  better.    Temperature,  38.3°  C. 

February  28. 

Dog  still  better.  There  was  no  doubt  that  convalescence  would 
be  uninterrupted.     Wound,  clean.     Temperature,  37.8°  C. 


Group  III 

Injection  Intravenously 

EXPERIMENT    22 

January  6,  191 1. 

Mongrel  dog;  weight,  11  kilos;  condition,  good.  This  was  a  dog 
that  had  previously  recovered  from  an  experiment  in  which  a  portion 
of  his  small  intestine  had  been  ligated  for  10  hours  and  then  removed. 


ANEMIA  OF  THE  SMALL  INTESTINE  187 

Ether.  Five  c.  c.  of  intestinal  extract  were  injected  into  the  exter- 
nal jugular  vein  at  10:15  a.m.  Temperature,  35.0°  C.  immediately 
after  stopping  the  ether.  At  4  :oo  p,  m.  it  had  risen  to  38.9°  C. ;  the 
pulse  was  112,  and  the  respiration  26. 

January  7. 

8  :oo  A.  M. — Temperature,  38.9°  C. ;  pulse,  128 ;  respiration,  24. 

January  8. 

7:30  A.M. — Temperature,  40.0°  C;  pulse,  120;  respiration,  18. 
Appetite  and  general  condition,  good. 

January  9. 

11:00  A.M. — Temperature,  38.9°  C. ;  pulse,  160;  respiration,  18. 
The  high  pulse  was  probably  due  to  the  fact  that  the  dog  had  been 
disturbed  considerably  when  his  temperature  was  taken. 

January  10. 

8:00  A.M. — Temperature,  38.9°  C. ;  pulse,  176;  respiration,  18. 
From  this  date  on  the  dog  made  an  uninterrupted  recovery. 

In  this  experiment  the  question  arises  as  to  whether  or  not  the 
previous  gut-ligation  for  10  hours  did  not  confer  a  certain  amount 
of  immunity  against  the  injection  of  intestinal  extract. 


EXPERIMENT    23 

January  16,  191 1. 

Spaniel  dog;  weight,  8.5  kilos;  condition,  good.  At  9:30  a.m. 
10  c.  c.  of  intestinal  extract  were  injected  into  the  external  jugular 
vein.  Vomiting  and  bloody  diarrhea  soon  followed,  and  the  dog  was 
very  sick.  At  3:15  p.m.  the  dog  was  cold  and  rigid.  Temperature, 
38.6°  C;  pulse,  yd;  respiration,  44.  At  8:00  p.  m.,  ii  hours  after  the 
injection,  death  occurred. 

EXPERIMENT    24 

January  16,  191 1. 

Mongrel  dog;  weight,  12.5  kilos;  condition,  good.  At  9:00  a.m. 
10  c.  c.  of  intestinal  extract  were  injected  into  the  external  jugular 
vein.  Constant  vomiting  followed,  and  a  bloody  stool  was  passed.  At 
3:15  p.m.  the  temperature  was  38.7°  C,  the  respiration  40,  and  the 
pulse  too  feeble  to  count.  Death  occurred  at  3 :30  p.  m.,  6>^  hours 
after  the  injection. 


l88  SURGICAL  ANEMIA  AND  RESUSCITATION 

Group  IV 

Injection  Intraperit  one  ally  of  Intestinal  Juice  from  a 
Dead  Dog 

EXPERIMENT    25 

November  19,  1909. 

Mongrel  dog;  weight,  7.2  kilos;  condition,  good.  At  9:00  a.m. 
the  temperature  was  38.5°  C,  the  pulse  114,  and  the  respiration  24. 
Ten  c.  c.  of  intestinal  extract,  made  from  the  small  intestine 
of  a  dog  that  had  been  dead  for  6^  hours,  was  injected  intra- 
peritoneally.  At  4:00  p.m.  the  dog  was  very  sick  and  cold.  No 
knee-jerks  or  reflexes  from  a  lighted  match  held  near  the  eyes  could 
be  obtained.  The  muscles  were  rigid.  Temperature,  39.5°  C. ;  pulse, 
84;  respiration,  22.  At  10:59  the  temperature  was  38.4°  C. ;  the  pulse, 
84;  and  the  respiration,  18.  There  were  still  absolutely  no  reflexes  to 
be  obtained,  and  the  condition  of  collapse  was  profound.  Death  oc- 
curred at  7:30  A.M.,  22^  hours  after  the  injection.  The  autopsy 
showed  peritonitis  to  be  present. 


EXPERIMENT    26 

November  18,  1909. 

Mongrel  dog;  condition,  good.  Temperature,  37.2°  C. ;  pulse,  84; 
respiration,  32.  At  this  time  10  c.  c.  of  intestinal  extract  from  the 
intestines  of  dogs  dead  for  16  hours  were  injected  intraperitoneally. 
The  dog  became  weak  and  sick,  and  soon  began  to  suffer  from  diar- 
rhea. At  12:15  p.  M.  the  temperature  was  34.4°  C,  the  pulse  96,  and 
the  respiration  24.  Neither  knee-jerks  nor  eye  reflexes  could  be 
obtained.  At  3  :oo  p.  m.  the  dog  was  having  convulsions,  his  tempera- 
ture was  still  subnormal,  and  he  felt  cold  to  the  touch.  Reflexes  were 
still  absent.  At  3:45  the  dog  was, dying.  He  seemed  to  be  suffering 
from  great  pain,  for  which  morphia,  q.  s.,  was  given.  Death  occurred 
shortly  after  this  observation,  8  hours  after  the  injection. 

Autopsy. — There  was  much  free  fluid  in  the  abdomen,  but  no 
peritonitis.  The  intestines  were  not  dark  in  color,  as  they  were  in 
the  dogs  receiving  intestinal  extract  from  gangrenous  intestine. 


ANEMIA  OF  THE  SMALL  INTESTINE  189 

Group  V 

Injection  of  Sterilized  Intestinal  Extract  ( i)  Intravenously 
and  (2)  Intraperitoneally 


EXPERIMENT    27 

December  22,  1910. 

Mongrel  dog;  condition,  good.  Intestinal  extract  was  heated 
for  one  hour  to  56°  C.  on  two  successive  days.  On  injecting  5.c.  c. 
into  the  external  jugular  vein  the  respiration  immediately  increased 
from  20  to  60,  and  the  pulse  got  very  weak  and  rapid.  In  5  minutes 
the  respiration  fell  to  30,  but  the  pulse  continued  weak  and  rapid, 
rate  of  160.  The  next  day  the  dog  was  not  sick  at  all,  and  a  com- 
plete recovery  was  made. 

EXPERIMENT    28 

January  7,  191 1. 

Mongrel  dog ;  weight,  9  kilos ;  condition,  good.  Five  c.  c. 
of  the  sterilized  toxin  used  in  the  last  experiment  were  injected  into 
the  external  jugular  vein  at  9:00  a.  m.  At  7:00  p.  m.  the  pulse  was 
too  rapid  to  count,  the  temperature  was  39.2°  C,  and  the  respiration 
56.  The  dog  was  sick,  refused  food,  drank  water,  had  incoordinated 
movements,  and  had  bloody  diarrhea. 

January  8. 

General  condition,  good.  Temperature,  38.0°  C. ;  pulse,  60;  respi- 
ration, 20.    After  this  recovery  soon  followed  and  was  complete. 


EXPERIMENT    29 

January  7,  191 1. 

Mongrel  bitch ;  weight,  8  kilos ;  condition,  good.  Five  c.  c.  of 
the  same  sterilized  extract  that  was  used  in  the  other  two  experi- 
ments in  this  group  were  given  intraperitoneally.  The  effect  was 
very  slight,  if  present  at  all  at  any  time,  and  the  bitch  made  an  unin- 
terrupted recovery. 


190 


SURGICAL  ANEMIA  AND  RESUSCITATION 


Injection  into  Dogs  of  Intestinal  Extract  from  Gangrenous 

Intestine  of  Dogs,  or  of  Extract  from  Intestine 

of  Dead  Dogs 


Experiment 
Number 


Weight  of 
Dog 


Amount  of  Ex- 
tract Injected 


Where  Injected 


Results 


Group  I: 


13 
14 

Group  II: 
IS 

16 
17 
18 


Group  III: 

22 
23 
24 

Group  IV: 2 

25 

26 

Group  V;  3 
27 

28 
29 


4.9  kilos 
4.2  kilos 

ii.o  kilos 
g.o  kilos 

14.0  kilos 
7 .  o  kilos 

7 . 5  kilos 
6 .  o  kilos 

10. o  kilos 
g.S  kilos 

15.3  kilos 


II  .0  kilos 
8.5  kilos 
12.5  kilos 


7.2  kilos 


10  c.  c. 
10  c.  c. 
10  c.  c. 
8  c.  c. 
10  c.  c. 
20  c.  c. 
10  c.  c. 
20  c.  c. 
10  c.  c. 

10  c.  c. 
10  c.  c. 
10  c.  c. 
10  c.  c. 
17  c.  c. 

60  c.  c.    in    divided 

doses 
20  c.  c.  at  one  time 

30  c.  c. 

10  c.  c. 

300  c.  c.  at  one  time 
20  c.  c. 
10  c.  c. 


5  c  .c. 
10  c.  c. 
10  c.  c. 


9.0  kilos 
8 .  o  kilos 


10  c.  c. 
10  c.  c. 


5  c.  c. 
5  c.  c. 


Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 
Peritoneal 


cavity 
cavity 
cavity 
cavity 
cavity 
cavity 
cavity 
cavity 
cavity 


Peritoneal  cavity 
Peritoneal  cavity 
Peritoneal  cavity 
Peritoneal  cavity 
Peritoneal  cavity 


Jejunum 

Duodenum 

Jejunum 

Jejunum 

Jejunum 

Duodenum 

Duodenum 


External  jugular  vein 
External  jugular  vein 
External  jugular  vein 


Intraperitoneally 
Intraperitoneally 


Ext.  jugular  vein 

Ext.  jugular  vein 
Intraperitoneally 


Death  after  6  hours 

Death  after  83^  hours 

Death  after  12  hours 

Death  after  16}^  hours 

Recovery 

Recovery 

Death  after  15  hours 

Recovery 

Death    after    about    18  H 

hours 
Recovery 

Death  after  about  14  hours 
Recovery 

Death  after  21  hours 
Death  after  about  15  hours 


Recovery,  but  dog  verj'  ill 

Death  after  4  hours 
Death  after  about  18  hours 
Recovery,    some    prostra- 
tion 
Recovery,  but  very  ill 
Recovery,  but  very  ill 
Recovery,  but  very  ill 


Recovery,  very  ill ' 
Death  after  11  hours 
Death  after  63^  hours 


Death,  22}^  hours 
Death  after  8  hours 


Recovery  after  temporary 

disturbance 
Recovery,  ill 
Recovery,  no  effect 


>  This  dog  had  probably  previously  acquired  immunity — see  experimental  details. 

2  Extract  made  from  intestines  of  dead  dogs. 

3  The  extract  ordinarily  used,  but  sterilized  by  heating. 


\ 

?;5;'/'-     .-^N-     . 

1  * 

*»! 

--■ 

^G- 

'f'y 

'/l~             •  ; , 

■'•  4:.- 

J'  9 

'%'  - 

j'..J,' 

a 

0* 

^ssiife*- 

■■-'C^' 

P/- 

Fig.  VII. — Cortex  from  Normal  Dog. 


Fig.  VIII. — Cortex  from  Toxemic  Dog. 


Brain  Cell  Changes  Produced  by  Toxemia  Due  to  Anemia  of  the 
Small  Intestines  of  a  Dog. 


ANEMIA  OF  THE  SMALL  INTESTINE  191 

Summary  of  Experiments  on  the  Injection  info  Dogs  of  Intes- 
tinal Extract  from  Gangrenous  Intestine  of  Dogs 
or  of  Extract  from  Intestines  of  Dead  Dogs 

Group  I. — Injection  into  the  peritoneal  cavity. 

Number  of  experiments 14 

Recoveries  5 

Deaths    9  (64.2%) 

Group  II. — Injection  into  the  lumen  of  the  intestine. 

Number  of  experiments 7 

Recoveries  5 

Deaths    2  (28.5%) 

Group  III. — Injection  intravenously. 

Number  of  experiments ■  3 

Recoveries i  ^ 

Deaths   2  (66.2/3%) 

Group  IV. — Injection  intraperitoneally  of  extract  from  intestines  of 
dead  dogs. 

Number  of  experiments 2 

Recoveries  o 

Deaths    2  (100%) 

Group  V. — Injection  of  sterilized  intestinal  extract,  such  as  was  used 
unsterilized  in  Groups  I-III,  inc. 

Number  of  experiments  ^ 3 

Recoveries  3 

Deaths    o  (0%) 

*  This  dog  may  have  been  rendered  immune  by  a  previous  experiment. 
2  Two  intravenously,  one  intraperitoneally. 

From  both  of  the  series  of  experiments  just  presented  one 
fact  stood  out  with  striking  clearness,  and  this  was  the  very 
poisonous  nature  of  the  substances  absorbed  into  the  circula- 
tion from  the  gangrenous  gut,  or  injected  into  the  circulation 
in  the  form  of  extract.  The  symptoms  of  collapse  were  prac- 
tically always  severe,  and  were  followed  (or  accompanied)  by 
either  a  rise  or  fall  of  temperature.  The  change  of  tempera- 
ture in  either  direction  might  amount  to  several  degrees. 


192  SURGICAL  ANEMIA  AND  RESUSCITATION 

When  the  gut  was  obstructed  the  symptoms  were  neces- 
sarily those  of  intestinal  obstruction.  When  the  gut  was  not 
obstructed,  or  when  extract  was  injected,  the  symptoms  were 
identical,  showing  that  in  clinical  cases  of  intestinal  obstruc- 
tion the  mere  fact  of  obstruction  is  of  importance  at  least  in 
part  because  it  causes  damming  of  the  intestinal  contents  with 
increased  toxin  formation  from  increased  bacterial  activity, 
and  subsequent  increased  absorption  of  the  toxins.  As  long  as 
there  is  gangrenous  bacteria-laden  gut  present,  even  if  only 
detached  in  the  abdominal  cavity,  poisoning  will  result  from 
the  toxins  which  get  into  the  circulation  by  way  of  the  peri- 
toneal lymphatics. 

In  Experiments  27,  28,  and  29  of  the  second  series  steril- 
ized intestinal  extract  was  injected  intravenously  twice  and 
intraperitoneally  once,  and  all  three  dogs  lived.  Apparently, 
therefore,  the  living  bacteria  present  in  either  gangrenous,  gut 
or  extract  made  from  it  play  an  important  part  in  the  poison- 
ing. That  the  poisons  are  present  when  the  bacteria  are  dead 
is  indicated  in  Experiments  2^  and  28,  in  which  the  symptoms 
which  followed  the  intravenous  injection  of  sterile  extract 
were  identical  with  those  caused  by  the  non-sterile  extract. 
Probably  products  formed  during  tissue  decomposition  act 
together  with  the  toxins  from  bacteria.  In  Experiment  29  no 
symptoms  occurred,  but  the  dose  of  5  c.  c.  was  but  half  that 
ordinarily  given  intraperitoneally. 

In  regard  to  toxemia  from  gangrenous  gut,  the  amount  of 
gut  involved  was  a  minor  detail.  Gangrene  of  10  centimeters 
of  intestine  caused  just  as  severe  symptoms  as  did  gangrene 
of  30  centimeters.  A  much  more  important  factor  was  the 
length  of  time  to  which  the  dog  was  exposed  to  the  toxemia. 

In  the  ligation  experiments  it  was  shown  that  the  small 
intestine  of  a  dog  will  not  endure  complete  anemia  for  a  longer 
period  than  6  hours  without  becoming  gangrenous.     More- 


<^ 


.  ^ 


'€ 


fe    --_ 


'^  ; 


>      ^ 


5 


T^-l^, 


■\ 


■^ 
f' 


-^ 


e 


^  A 


^  .. 


us 


Wrf 


C^'"^-, 


-^^/f±t 


TTUT? 


V'2 


,-^      <t^ 


c  ^^ 


^•'^S' 


Fig.  IX.— Cerebellum  from  Normal  Dog.  Fig.  X.— Cerebellum  from  Toxemic  Dog. 

Brain  Cell  Changes  Produced  by  Toxemia  Due  to  Anemia  of  the 
Small  Intestines  of  a  Dog. 


ANEMIA  OF  THE  SMALL  INTESTINE  193 

over,  as  shown  by  Experiments  10  and  23,  first  series,  anemia 
of  five  hours  may  or  may  not  cause  gangrene.  It  is  conserva- 
tive to  state  that  anemia  of  3  hours'  duration  is  not  perma- 
nently harmful  to  the  intestine,  and  that  the  danger  of  partial 
or  total  gangrene  is  in  direct  ratio  to  the  length  of  time  above 
three  hours  that  anemia  continues. 

CONCLUSIONS 

From  the  data  of  this  research  a  very  important  principle 
is  established  in  operations  for  gangrene  of  the  intestine,  viz., 
that  the  patient  must  be  protected  at  all  hazards  against  the 
absorption  of  the  exceedingly  toxic  fluid  in  the  gangrenous 
tissue.  The  author  has  witnessed  death  following  a  most 
careful  excision  of  a  coil  of  gangrenous  bowel  despite  the 
fact  that  the  patient  left  the  table  in  good  condition  and  that 
there  was  absence  of  peritonitis  following  the  operation. 

The  clinical  symptoms  in  such  cases  are  largely  cerebral. 
The  patient  becomes  restless,  delirious,  and  unconscious,  and 
is  usually  entirely  free  from  pain.  The  pulse  and  respiration 
become  rapid,  the  tongue  dry,  the  temperature  either  high  or 
subnormal.  There  is  usually  diarrhea  and  distention  of  the 
abdomen  without  rigidity  or  tenderness.  Further  researches 
have  shown  that  the  real  lesion  is  in  the  brain  cells.  There- 
fore, when  operating  upon  a  case  of  obstruction  with  a  loop 
of  gangrenous  intestine  present,  large  clamps  should  at  once 
be  placed  on  the  healthy  intestine  in  such  a  manner  that  none 
of  the  poisonous  substance  can  be  squeezed  into  the  circulation 
and  thus  reach  the  brain.  Then,  and  only  then,  may  the  gan- 
grene be  removed  with  safety. 

Another  point  of  clinical  importance  which  the  experi- 
ments demonstrated  is  that  the  toxin  due  to  anemic  gangrene 
requires  several  hours  to  cause  the  first  symptoms.    The  injec- 


194  SURGICAL  ANEMIA  AND  RESUSCITATION 

tion  experiments,  especially  the  intravenous  injections,  show 
that  a  single  dose  of  sterile  toxin  can  cause  grave  sickness  and 
even  death.  When  a  patient  with  gangrenous  intestine  has  a 
certain  degree  of  mental  impairment  he  may  have  at  that 
moment  his  fatal  dose  of  toxin.  This  fact  emphasizes  the 
importance  of  refraining  from  handling  gangrenous  intestine, 
and  even  more  emphasizes  the  importance  of  early  diagnosis, 
and  the  absurdity  of  waiting  for  constitutional  symptoms  in 
cases  of  obstruction  before  advising  operation. 

In  cases  of  acute  intestinal  obstruction  the  most  important 
lesions  are  in  the  brain  (see  Figs.  VII,  VIII,  IX  and  X). 


CHAPTER  IX 

ANEMIA  OF  THE  KIDNEYS  AND  SPLEEN 

ANEMIA  OF  THE  KIDNEYS 

Within  the  last  ten  years  there  has  been  a  renewal  of  in- 
terest in  the  study  of  the  circulation  in  the  kidneys.  Compara- 
tively few  investigators,  however,  have  attacked  the  problem 
from  the  very  practical  operative  standpoint  of  determining 
how  long  the  renal  pedicle  may  be  compressed  to  the  point  of 
total  obliteration  of  circulation  without  causing  damage  to  the 
renal  structure;  in  other  words,  how  long  the  kidneys  can 
endure  complete  anemia  without  injury.  It  is  not  the  inten- 
tion here  to  discuss  the  problems  of  infarction.  Very  recently 
Karsner  and  Austin  have  published  an  account  of  experimental 
work  of  their  own,  in  which  they  give  a  good  review  of  the 
literature  of  renal  infarction,  beginning  with  the  classical  work 
of  Litten. 

Litten  found  that  the  kidney  of  a  dog  or  rabbit  could  not 
have  its  blood  supply  shut  off  for  more  than  from  one  and 
one-half  to  two  hours  without  showing  marked  changes. 
After  long  protracted  anemia  the  changes  varied  in  intensity 
rather  than  in  the  extent  of  involvement. 

Carrel  has  shown  that  a  kidney  may  be  deprived  of  its 
circulation  for  from  fifty  minutes  to  an  hour  and  a  half  and 
may  then  be  successfully  implanted  either  into  another  animal 
or  back  into  its  original  place.  In  one  striking  experiment  he 
reports  the  removal  of  a  kidney,  its  reimplantation  into  the 

195 


196  SURGICAL  ANEMIA  AND  RESUSCITATION 

same  animal,  and  the  subsequent  removal  of  the  remaining 
kidney.  During  the  operation  the  reimplanted  kidney  was 
necessarily  deprived  of  its  circulation  for  fifty  minutes,  but  was 
perfused  with  Locke's  solution  during  this  time.  The  animal, 
thus  depending  for  renal  function  on  the  one  reimplanted  kid- 
ney, was  living  and  healthy  at  the  end  of  23  months,  and, 
moreover,  had  subjected  her  kidney  to  unusual  strain  during 
two  pregnancies,  which  resulted  in  a  total  of  14  puppies. 
More  striking  evidence  than  this  that  the  kidney  of  a  dog  can 
endure  anemia  of  50  minutes  and  maintain  functional  effi- 
ciency could  scarcely  be  presented. 

In  order  to  observe  "how  long  the  circulation  through  the 
renal  vessels  can  be  completely  obstructed  without  causing 
permanent  degenerative  changes  in  the  kidney,"  •  Eisendrath 
and  Strauss  clamped  the  renal  vessels  of  five  rabbits  for  15, 
30,  45,  60,  and  90  minutes,  respectively,  and  then  studied  the 
effect  on  the  kidney  after  four  weeks  had  elapsed.  In  two 
more  experiments  the  circulation  was  occluded  for  two  hours 
in  each.  In  the  first  the  rabbit  was  killed  immediately,  while 
in  the  second  it  was  killed  at  the  end  of  48  hours. 

After  the  clamps  had  been  applied  for  two  hours  the  gross 
effect  was  to  cause  the  kidney  to  swell  and  become  cyanotic 
in  a  marked  way.  The  late  effects  were  quite  different,  as 
in  the  90-minute  experiment  the  kidney  was  diminished  in  size 
when  compared  with  the  other  kidney  of  the  same  animal, 
was  paler  in  color,  and  showed  gross  evidence  of  parenchy- 
matous degeneration.  In  the  experiments  in  which  the  com- 
pression was  for  less  than  90  minutes  the  size  was  not  mater- 
ially changed,  although  in  the  one-hour  experiment  the  kidney 
was  much  smaller  and  when  cut  showed  parenchymatous  de- 
generation. The  histologic  changes  were  very  slight  when  the 
clamps  had  been  applied  for  half  an  hour  or  less,  but  in  as 
short   an  additional   time   as    15    minutes   considerable    par- 


ANEMIA  OF  THE  KIDNEYS  197 

enchymatous  degeneration  and  interstitial  infiltration  were 
caused. 

In  comparing  the  results  of  Eisendrath's  and  Strauss's  ex- 
periments with  those  of  Carrel  it  must  be  remembered  that 
the  rabbit  kidney  is  more  sensitive  to  anemia  than  the  dog 
kidney.  Moreover,  in  Carrel's  experiments  the  kidneys  were 
removed  and  perfused  with  Locke's  solution,  and,  while  the 
latter  may  have  had  a  beneficial  influence,  the  work  of  Guthrie 
would  indicate  the  contrary.  Guthrie  found  that  a  perfused 
kidney  would  not  endure  anemia  so  well  as  a  kidney  which 
had  been  anemic  alone.  In  his  experiments  on  cats  anemia 
of  less  than  an  hour  did  not  cause  marked  changes  in  the 
renal  structure. 

MacNider  experimented  on  cats,  permanently  ligating  the 
posterior  branch  of  the  renal  artery  of  one  kidney.  He  found 
that  ischemia  always  followed  in  the  part  supplied  by  this 
branch ;  that  a  more  or  less  imperfect  collateral  circulation  de- 
veloped, which  first  appeared  in  the  medulla  and  later  invaded 
the  cortex ;  that  by  the  twenty-fifth  day  following  occlusion  the 
zone  of  distribution  was  rather  diffusely  pink  from  a  more  or 
less  even  distribution  of  the  carmin  injected  into  the  blood 
vessels,  the  medulla  always  containing  more  of  the  carmin 
mass  than  the  cortex,  and,  finally,  that,  with  the  development 
of  obliterative  changes  in  the  vessels,  the  carmin  again  be- 
came more  irregularly  distributed  in  the  ligated  zone.  For 
the  detailed  and  long  description  of  the  histologic  changes 
which  he  found,  the  reader  is  referred  to  the  original  article. 

From  his  study  as  a  whole  MacNider  concluded  that 
ligation  of  the  posterior  branch  of  the  renal  artery  leads  to 
necrosis  of  the  greater  portion  of  the  cortex  and  of  the  super- 
ficial portion  of  the  medulla  of  approximately  the  posterior 
one-third  of  the  kidney;  that  an  imperfect  anastomosis  be- 
tween the  vessels  of  the  two  vascular  zones  is  possible  and  does 


1 98  SURGICAL  ANEMIA  AND  RESUSCITATION 

develop;  that,  with  the  development  of  the  anastomosis,  there 
is,  at  first,  an  ingrowth  of  connective  tissue  cells  into  the  ne- 
crotic zone,  followed  by  an  ingrowth  of  renal  epithelium;  and 
that  some  of  the  glomeruli  are  regenerated  by  an  ingrowth  of 
capillary  buds,  which  later  become  canalized  and  contain  blood. 
Finally,  a  secondary  fibrosis  is  inaugurated  and,  with  its  de- 
velopment, there  is  an  atrophy  of  renal  tubules,  fibrosis  of 
the  glomeruli,  and  obliterative  changes  in  the  vessels,  the  re- 
sulting picture  being  comparable  to  a  chronic  interstitial  neph- 
ritis. 

In  regard  to  the  problem  of  regeneration  of  renal  tissue,  as 
MacNider  points  out,  the  recent  work  of  Burrows  and  Carrel 
is  illuminating.  After  the  inoculation  of  plasmatic  media  with 
small  fragments  of  kidney  from  a  cat,  exceedingly  active 
growth  of  the  renal  cells  took  place.  In  one  experiment  it 
was  found  that  new  epithelial  tubules  had  grown  by  the  begin- 
ning of  the  7th  day.  As  the  authors  expressed  it:  "A  few 
tubes  composed  of  a  lumen  and  limited  by  epithelial-like  cells 
had  passed  from  the  fragment  of  the  kidney  for  a  distance  into 
the  plasmatic  medium.  They  had  the  appearance  of  renal 
tubules." 

In  considering  the  effects  of  total  anemia  on  the  kidney  it 
should  be  remembered  that  considerable  histologic  change  may 
not  be  inconsistent  with  a  certain  amount  of  renal  function. 
This  fact  is  brought  out  in  the  author's  experiments. 

Coming  to  the  work  on  renal  anemia  done  in  the  author's 
laboratory,  the  experiments,  all  on  dogs,  were  divided  into 
three  groups,  as  follows: 

Group  I.  Experiments  in  which  the  renal  artery  alone  of 
the  right  kidney  was  clamped  for  periods  varying  from  five 
minutes  to  four  hours  (the  renal  vein  and  ureter  were  not 
included). 

Group  II.     Experiments  in  which  both  the  renal  artery 


ANEMIA  OF  THE  KIDNEYS  199 

and  vein  of  the  right  kidney  were  clamped  for  varying  periods 
of  time. 

Group  III,     Experiments  on  dogs  from  which  one  kidney 
had  previously  been  removed. 


Group  I 
Experiments  in  Which  the  Renal  Artery  Alone  was  Clamped 

EXPERIMENTS    1-5    INC. 

In  these  and  in  all  of  the  following  experiments  ether  was  the 
anesthetic  used.  With  these  five  dogs  the  renal  artery  of  the  right 
kidney  was  clamped  for  a  period  varying  from  5  to  35  minutes  (5,  15, 
20,  25,  35).  In  all  instances  urine  continued  to  be  secreted  after  the 
temporary  ligation,  and  in  only  one — the  35-minute  dog — did  blood 
appear  in  the  urine.  All  of  the  kidneys  were  removed  at  the  end  of 
nine  days,  and  sections  cut,  stained,  and  examined  microscopically. 

No  permanent  changes  were  found  in  kidneys  rendered  anemic  for 
less  than  25  minutes,  but  in  the  25-minute  and  35-minute  experiments 
varying  degrees  of  epithelial  desquamation  and  edema  had  taken  place. 
An  early  change  noted  was  the  breaking  of  the  nuclear  membrane 
with  diffusion  of  the  nuclear  chromatin  through  the  cytoplasm.  This 
condition  evidently  followed  the  edematous  condition  of  the  cell  after 
the  circulation  was  allowed  to  return  when  the  clamp  was  removed. 
Judging  from  later  experiments  it  was  not  an  irremediable  change. 
A  more  detailed  study  of  a  30-minute  ligation  is  given  in  the  next 
experiment. 

EXPERIMENT    6 

January  6,  19 10. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  Under  careful 
asepsis  the  right  kidney  was  exposed  and  the  renal  artery  clamped  for 
50  minutes.  When  the  clamp  was  removed  there  was  no  hemorrhage 
from  the  capsule,  nor  could  definite  pulsations  be  made  out  in  the 
kidney.  A  specimen  of  urine  was  not  obtained,  but  a  gauze  sponge 
that  was  held  in  place  over  the  penis  by  a  bandage,  when  soaked  in  a 
small  amount  of  water,  did  not  give  a  positive  reaction  with  the  ben- 
zidin  test  for  blood.  The  dog  was  carefully  observed  for  a  week, 
but  showed  no  ill  effects  from  the  experiment. 


200  SURGICAL  ANEMIA  AND  RESUSCITATION 

January  14,  19 10. 

The  dog  was  again  anesthetized  and  the  kidney  exposed.  The 
ureter  was  compressed  for  twenty  minutes.  This  caused  the  pelvis 
of  the  kidney  to  dilate,  and,  on  dividing  the  ureter,  a  small  quantity  of 
urine  flowed  from  it.  This  was  found  to  contain  a  few  hyaline  casts 
and  some  blood  cells.  The  latter  doubtless  came  from  the  edges  of 
the  cut  ureter  rather  than  from  the  kidney. 

On  removing  the  kidney  after  separating  a  few  adhesions  around 
it,  it  was  found  that  very  few  macroscopic  changes  had  occurred.  The 
capsule  was  somewhat  thickened  and  adherent,  but  the  line  of  de- 
marcation between  cortex  and  medulla  was  preserved.  The  renal 
pelvis  contained  calcareous  material,  but  no  well-formed  calculi. 
There  were  no  signs  of  hemorrhage.  Blocks  from  various  parts  were 
removed  and  sections  made. 

Microscopical  Examination. — The  tubular  epithelium  showed 
an  unevenly  distributed  desquamation,  and  where  this  was  absent  the 
portions  of  the  cells  toward  the  lumina  had  a  ragged  border.  Under 
a  higher  magnification  the  nuclear  chromatin  was  seen  to  have  passed 
out  into  the  cytoplasm  in  many  of  the  cells,  and  in  some  there  was 
nothing  but  a  shadow  of  the  nucleus  remaining.  In  these  cells  the 
staining  was  diffuse  and  pale.  Some  of  the  tubules  contained  hyaline 
and  epithelial  casts,  but  they  were  not  nearly  so  numerous  as  in  ex- 
periments in  which  the  time  of  ligation  was  longer.  Diapedesis  had 
occurred  from  the  glomeruli,  the  contour  of  the  glomerular  vessels  not 
being  made  out.  About  the  glomeruli  there  was  marked  round-cell 
infiltration,  which  varied  in  different  parts  of  the  kidney,  but  seemed 
to  be  most  marked  near  the  renal  capsule.  In  some  areas  there 
seemed  to  be  a  certain  amount  of  connective  tissue  proliferation. 
Where  it  was  present  there  was  a  corresponding  narrowing  of  the 
lumina  of  the  tubules.  This  was  confined  almost  entirely  to  the 
portion  of  the  kidney  nearest  the  capsule  where  the  blood  supply 
was  smallest. 

EXPERIMENT    7 
January  8,  1910. 

Mongrel  bitch;  condition,  good.  Ether  anesthesia.  The  right 
kidney  was  exposed,  and  the  renal  artery  clamped  for  ^5  minutes. 
There  was  no  injury  of  the  kidney  nor  hemorrhage  from  the  capsule 
when  the  clamp  was  removed.  The  incision  was  then  closed  and  the 
bitch  returned  to  the  kennel. 

January  9. 

The  bitch  seemed  to  be  in  good  condition.  Pulse  rate  and  tem- 
perature normal.    A  specimen  of  urine  was  obtained  by  pressing  over 


ANEMIA  OF  THE  KIDNEYS  20l 

the  bladder.  This  gave  a  positive  benzidin  reaction  for  blood  and 
contained  albumin.  The  blood  test  was  made  every  day  after  this 
for  seven  days,  but  was  never  again  positive.  The  albumin  was  con- 
stantly present  during  this  time,  although  in  decreasing  amount. 

January  19. 

The  bitch  was  again  anesthetized,  the  kidney  exposed,  and  the 
ureter  severed.  Urine  flowed  from  the  ureter,  and  was  found  to  con- 
tain hyaline  and  epithelial  casts.  The  kidney  was  then  removed  and 
split  open.  The  capsule  was  thickened  and  edematous,  and  more  ad- 
herent than  normal,  but,  beyond  slight  general  enlargement  of  the 
kidney,  there  were  no  other  macroscopical  changes. 

Microscopical  Examination. — Marked  desquamation  of  the  tu- 
bular epithelium,  with  round-cell  infiltration  around  the  tubules  and 
glomeruli,  was  present.  The  latter  was  usually  in  proportion  to  the 
former.  Throughout  the  cortex  there  were  newly  formed  blood  ves- 
sels, extending  inward  from  the  capsule,  and  this  in  spite  of  the  fact 
that  there  had  been  no  adhesions  between  the  kidney  and  its  bed. 
The  glomeruli  were  edematous.  Their  finer  structure  could  not  be 
made  out.  Most  of  them  showed  interglobular  hemorrhage  and  a  sur- 
rounding zone  of  round-cell  infiltration,  as  already  mentioned.  Under 
an  oil  immersion  lens  breaking  of  the  nuclear  membrane  could  be 
made  out  with  diffusion  of  the  chromatin  into  the  cytoplasm.  The 
desquamation  of  the  tubular  epithelium,  or  raggedness  of  the  parts  of 
the  cells  toward  the  lumina,  could  be  seen  even  more  clearly.  In 
areas  where  the  blood  supply  was  less  abundant  there  was  extensive 
proliferation  of  connective  tissue  cells,  and  in  other  places  this  was 
also  present,  but  in  lesser  degree.  As  found  in  the  other  experiments 
this  proliferation  was  accompanied  by  narrowing  of  the  lumina  of 
the  tubules,  and  occasionally  by  their  actual  obliteration. 

In  this  instance  the  changes  were,  at  least  in  part,  of  a  perma- 
nent nature,  in  spite  of  the  fact  that  the  kidney  was  still  capable  of 
secreting  urine.  It  seems  possible  that  a  kidney  with  such  changes 
might  have  remained  a  useful  organ. 


EXPERIMENT    8 

January  7,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right  kid- 
ney was  exposed,  and  the  artery  clamped  for  45  minutes.  There  was 
no  hemorrhage  from  the  capsule,  and  the  macroscopical  appearance 
was  normal.    The  operative  recovery  was  apparently  good,  and  when 


202  SURGICAL  ANEMIA  AND  RESUSCITATION 

the  dog  was  examined  at  night,  about  12  hours  after  the  operation, 
he  seemed  still  to  be  in  good  condition. 

January  8. 

The  dog  was  found  dead  in  the  morning  by  the  laboratory  as- 
sistant. At  the  autopsy  a  double  lobar  pneumonia  was  found,  as  well 
as  numerous  emboli  in  the  lungs.  An  examination  of  the  kidney  failed 
to  show  that  it  was  the  source  of  the  emboli,  but  the  kidney  was  much 
congested  and  swollen,  and  the  capsule  was  edematous  and  thickened. 

Microscopical  Examination. — The  entire  organ  was  edematous, 
but  more  especially  so  around  the  glomeruli.  The  tubules  contained 
blood  corpuscles,  detritus,  and  a  few  epithelial  casts.  The  scattering 
of  the  chromatin  from  the  nuclei  was  not  found  in  this  experiment, 
as  it  was  in  the  preceding  ones,  and  the  only  change  in  the  cells  them- 
selves seemed  to  be  edema.  The  chief  conclusion  drawn  from  the 
experiment  was  that  the  first  effect  of  the  return  of  circulation  after 
anemia  is  the  production  of  a  dropsical  condition,  and  that  this  is  fol- 
lowed by  diapedesis. 

EXPERIMENT    9 

December  4,  1909. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right  kid- 
ney was  exposed,  and  the  renal  artery  clamped  for  2  hours.  Just  be- 
fore the  clamp  was  removed  a  small  incision  was  made  through  the 
capsule.  There  was  no  bleeding  from  this  incision.  As  soon  as  the 
clamp  was  removed  free  bleeding  followed.  This  showed  that  the 
hemostasis  had  been  complete.  The  operative  recovery  was  good, 
and,  during  the  next  ten  days,  the  dog  showed  no  ill  effects  from 
the  experiment,  eating  and  drinking  as  did  the  other  dogs  in  the 
kennel. 

December  15. 

The  dog  was  again  anesthetized,  and  the  kidney  exposed  by  re- 
opening the  former  incision.  The  kidney  was  swollen  and  somewhat 
edematous  and  firmly  adherent  to  the  overlying  peritoneum  and  to 
the  renal  fossa.  About  the  site  of  the  former  incision  through  the 
capsule  there  were  evidences  of  an  old  hemorrhage.  On  excising  and 
splitting  the  kidney  numerous  small  hemorrhages  into  its  substance 
were  seen,  but  the  line  of  demarcation  between  cortex  and  medulla 
remained  very  distinct.  There  were  no  macroscopic  areas  of  colloid 
degeneration.  The  left  kidney  was  larger  than  normal,  but  showed 
no  other  change. 

Microscopical  Examination. — Throughout  the  entire  kidney 
there  had  been  extensive  interstitial  hemorrhages,  and  round-cell  in- 


ANEMIA  OF  THE  KIDNEYS  203 

filtration.  The  glomeruli  and  tubules  showed  extensive  desquamation 
of  the  lining  epithelium,  causing,  as  a  whole,  the  appearance  of  an 
acute  parenchymatous  nephritis.  The  epithelium  that  had  not  desqua- 
mated stained  poorly,  presenting  a  very  irregular  border  to  the  lu- 
mina  of  the  tubules.  Numerous  epithelial  casts  could  be  seen  in  the 
tubules.  The  latter  were  often  greatly  dilated,  and  most  markedly 
in  the  loop  of  Henle.  Everywhere  the  most  marked  changes  were 
found  in  the  glomeruli. 

EXPERIMENT    10 

December  4,  1909. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right 
kidney  was  exposed,  and  the  renal  artery  clamped  for  5  hours.  After 
removing  the  clamp  the  pallor  was  replaced  by  redness  and  conges- 
tion. In  a  few  minutes  small  bleeding  points  appeared  beneath  the 
capsule  in  some  places,  while  in  others  this  did  not  occur.  As  the 
kidney  had  not  been  traumatized  by  rough  handling  it  was  difficult  to 
account  for  this  other  than  by  the  fact  that  internal  changes  had  oc- 
curred. Moreover,  this  phenomenon  was  observed  in  several  of 
the  other  experiments  in  which  the  anemia  was  prolonged.  The 
wound  was  closed.     The  operative  recovery  was  good. 

December  15. 

The  dog  was  again  anesthetized,  and  the  right  kidney  removed 
with  difficulty,  owing  to  the  formation  of  dense  adhesions.  This 
kidney  was  considerably  larger  than  the  left.  It  was  very  edema- 
tous, and  had  subcapsular  hemorrhages.  Prior  to  removal  section 
of  the  ureter  showed  that  no  urine  was  flowing,  and  none  flowed  in 
an  hour,  even  with  a  small  cannula  in  the  proximal  end  of  the 
ureter  to  prevent  contraction.  On  splitting  the  kidney  numerous 
emboli  were  found,  and  many  areas  of  infarction  and  necrosis.  The 
line  of  demarcation  between  the  medulla  and  cortex  was  not  very 
distinct,  and  the  capsule  was  firmly  adherent. 

Microscopical  Examination. — Throughout  the  entire  organ 
marked  desquamation  had  occurred,  both  from  tubules  and  glomeruli, 
and,  in  the  former,  were  many  hyaline  and  epithelial  casts.  There 
was  extensive  round-cell  infiltration  around  the  tubules  and  hem- 
orrhage about  the  glomeruli.  Some  parts  of  the  medulla  had  been 
so  damaged  that  it  was  almost  impossible  to  recognize  the  different 
elements.  As  in  the  gross  appearance  the  lack  of  differentiation 
between  cortex  and  medulla  was  very  noticeable.  The  capsule  was 
both   thickened   and   adherent.     At  the  upper   pole   of   the   kidney 


204  SURGICAL  ANEMIA  AND  RESUSCITATION 

were  many   newly   formed  blood   vessels   passing   into   the   capsule 
from  the  surrounding  adhesions. 

EXPERIMENT    ii 

December  14,  1909. 

Black  and  tan  bitch ;  condition,  good.  Ether  anesthesia.  The 
right  kidney  was  exposed,  and  the  artery  clamped  for  554  hours.  At 
the  end  of  this  period  the  field  was  still  bloodless  before  removing  the 
clamp.  After  removing  it,  there  was  slight  oozing  from  the  capsule, 
which  continued  for  about  five  minutes,  and  blood  began  to  flow  again 
in  the  renal  vein.  A  small  sheet-rubber  drain  was  left  in  the  wound 
posterior  to  the  kidney  and  the  incision  closed  around  it.  Four 
hours  later  the  urine  from  the  bladder  gave  a  positive  benzidin  reac- 
tion. The  urine  was  tested  for  blood  twice  daily,  but  no  positive 
reaction  was  obtained  after  the  third  day.  The  bitch  was  in  good 
condition,  ate  well,  and  drank  large  quantities  of  water. 

December  23. 

The  bitch  was  again  anesthetized  and  the  kidney  exposed.  Be- 
fore dividing  the  ureter  it  was  gently  compressed  for  fifteen  minutes, 
but  there  was  no  flow  of  urine  from  it  at  the  end  of  that  time.  The 
appearance  of  kidney  and  ureter  did  not  differ  from  that  of  the  pre- 
ceding experiments,  where  the  anemia  was  of  long  duration.  The 
other  kidney  was  larger  than  normal,  but  otherwise  seemed  to  be 
normal.  The  right  kidney  was  removed.  The  urine  was  examined 
for  several  days.  Albumin  was  present  for  nine  days,  when  it  dis- 
appeared.    Blood  was  not  detected. 

Microscopical  Examination. — The  findings  were  identical  with 
those  of  the  three-  and  four-hour  experiments.  The  glomeruli  showed 
the  most  marked  changes  and  were  practically  destroyed.  In  the 
tubules  there  was  marked  desquamation,  while  around  them  was  the 
usual  round-cell  infiltration.  The  capsule  was  thickened  and  adherent, 
and  in  the  adhesions  new  blood  vessels  had  formed,  having  grown  into 
the  kidney  from  the  outside. 

EXPERIMENT    12 

December  8,  1909. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right  kid- 
ney was  exposed,  and  the  artery  clamped  for  4  hours.  On  removing 
the  clamp  the  kidney  became  congested  and  pulsating,  the  latter  a  phe- 
nomenon not  noted  in  any  of  the  other  experiments.  Numerous  bleed- 
ing points  soon  appeared  on  the  surface  of  the  kidney,  but  the  hemor- 
rhage soon  stopped.    Three  hours  after  the  operation  the  dog  seemed 


ANEMIA  OF  THE  KIDNEYS  205 

to  be  in  good  condition.  By  pressing  over  the  bladder  bloody  urine 
was  obtained.  The  dog  was  placed  in  a  separate  kennel,  with  a 
sponge  bandaged  in  place  over  his  penis. 

December  9. 

The  sponge  showed  no  macroscopic  evidence  of  blood,  but  gave  a 
positive  benzidin  reaction  when  soaked  in  water  and  the  solution 
tested.  The  same  reaction  was  obtained  on  the  next  day,  but  not 
thereafter.  The  incision  healed  by  first  intention,  and  the  dog  showed 
no  ill   effects   from  the   operation. 

December  19. 

The  dog  was  again  anesthetized  and  the  right  kidney  exposed.  It 
was  bound  firmly  down  by  adhesions  which  showed  a  network  of 
small  blood  vessels.  By  enlarging  the  incision  the  ureter  was  exposed 
and  divided  without  further  disturbing  the  kidney.  No  urine  was 
passed  in  an  hour.  The  kidney  was  then  removed  by  cutting  widely 
around  the  adherent  mass.  On  dissecting  out  the  renal  artery  from 
the  adhesions  it  was  found  to  contain  an  embolus  which  nearly  oc- 
cluded its  lumen.  In  the  renal  pelvis  there  was  a  considerable  deposit 
of  blood  and  calcareous  matter.  The  capsule  was  much  thickened, 
adherent,  and  showed  numerous  blood  vessels  extending  in  from  the 
surrounding  adhesions.  The  line  of  demarcation  between  cortex  and 
medulla  was  very  indistinct.  Throughout  the  renal  substance  numer- 
ous small  hemorrhages  hgd  occurred. 

Microscopical  Examination. — There  had  been  extensive  disin- 
tegration of  the  kidney  substance,  in  many  places  the  change  being  so 
great  that  no  normal  tissue  could  be  made  out.  The  glomeruli  were 
completely  disintegrated,  appearing  as  hyaline  masses.  The  epithelial 
desquamation  from  the  tubules  was  very  marked.  Numerous  epithelial 
casts  were  present  throughout  the  sections,  but  only  a  few  were 
found  in  the  pelvis  of  the  kidney.  In  one  area  there  had  been  some 
proliferation  of  the  tubular  epithelium,  but  no  structure  of  the  tubules 
could  be  made  out.  In  the  places  where  hemorrhage  had  occurred 
there  was  a  surrounding  round-cell  infiltration,  and  in  none  of  these 
places  could  any  of  the  original  structure  be  made  out. 

At  the  time  the  right  kidney  was  removed  the  other  kidney  was 
examined  and  found  to  be  somewhat  larger  than  the  right,  but  there 
was  not  as  much  difference  in  size  as  in  the  three-hour  experiments. 
Four  days  after  removal  of  the  right  kidney  the  dog  was  again  anes- 
thetized, the  left  kidney  exposed,  and  the  ureter  cut.  While  under  ob- 
servation for  thirty  minutes  albumin- free  urine  was  excreted.  (See 
Figs.  XI  and  XII.) 


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ANEMIA  OF  THE  KIDNEYS  207 

Group  II 

Experiments  in  Which  Both  the  Renal  Artery  and  Renal  Vein 

Were  Clamped 

EXPERIMENT    i 

January  15,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right 
kidney  was  exposed,  and  both  vein  and  artery  clamped  for  jo  minutes. 
The  incision  was  then  closed.    The  operative  recovery  was  good. 

January  25. 

The  dog  was  in  excellent  condition.  He  was  again  anesthetized, 
the  kidney  exposed  as  before,  and  found  to  be  secreting  urine  in  which 
no  casts  or  albumin  were  present.  While  there  were  a  few  surround- 
ing adhesions  the  kidney  seemed  in  every  way  to  be  normal.  The 
kidney  was  removed  and  sections  made. 

Microscopical  Examination. — While  there  was  some  desquama- 
tion of  the  tubular  epithelium  it  was  not  so  marked  as  in  the  30-minute 
experiment  in  which  the  artery  alone  was  clamped.  The  cells  showed 
a  dropsical  condition  similar  to  that  of  the  other  experiment,  but  the 
round-cell  infiltration  was  not  so  marked  nor  was  there  hemorrhage 
into  the  renal  substance.  A  few  of  the  tubular  epithelial  cells  showed 
diffusion  of  the  nuclear  chromatin,  but  this  also  was  less  marked  than 
when  the  artery  alone  was  clamped  for  the  same  length  of  time.  No 
casts  were  found  in  the  tubules.  No  evidence  of  connective  tissue 
proliferation  was  found,  and,  in  almost  every  respect,  the  kidney  ap- 
peared to  be  normal.  The  capsule  was  somewhat  thickened,  but  there 
had  not  been  any  formation  of  new  capillaries. 

EXPERIMENT    2 
January  16,  1910. 

Mongrel  bitch ;  condition,  good.  Ether  anesthesia.  The  right 
kidney  was  exposed,  and  both  artery  and  vein  clamped  for  4^  minutes. 
At  the  end  of  this  time  no  gross  changes  were  noted  after  the  blood 
had  again  entered  the  organ.  The  incision  was  closed,  and  the  bitch 
returned  to  the  kennel  in  good  condition. 

January  17. 

A  specimen  of  urine  was  obtained  by  pressing  over  the  bladder. 
No  blood  cells  were  found  in  sediment  obtained  by  centrifugalization, 
but  the  benzidin  test  was  positive.     Albumin  was  present  constantly 


2o8  SURGICAL  ANEMIA  AND  RESUSCITATION 

until  the  end  of  the  experiment,  while  the  benzidin  test  was  positive 
only  for  four  days. 

January  26. 

The  bitch  was  again  anesthetized,  and  the  right  kidney  exposed. 
The  ureter  was  divided.  For  twenty  minutes  urine  flowed  from  it.  The 
kidney,  as  a  whole,  was  swollen  and  surrounded  by  adhesions.  It 
was  removed  and  split.  The  capsule  was  much  thickened,  very 
adherent,  and,  on  stripping  it,  portions  of  the  cortex  came  away 
with  it.  The  entire  organ  seemed  to  be  edematous,  but  no  evidence 
of  hemorrhage  was  found. 

Microscopical  Examination. — Marked  epithelial  desquamation 
and  round-cell  infiltration  had  occurred.  The  cortex  was  very  ede- 
matous, and  did  not  stain  well.  The  glomeruli  appeared  as  homo- 
geneous masses,  devoid  of  any  structure  whatsoever.  Around  them 
there  was  considerable  hemorrhage.  The  most  marked  changes  were 
in  the  tubular  epithelium,  which,  in  some  places,  was  completely 
desquamated.  Cells  which  had  not  desquamated  had  either  a  swollen 
nucleus  or  dififusion  of  the  nuclear  chromatin  into  the  cytoplasm. 
These  cells  were  very  indefinite  in  structure.  The  condition  in  this 
kidney  was  worse  than  in  the  45-minute  experiment,  in  which  the 
artery  alone  was  clamped. 

EXPERIMENT   3 
January  19,  1910. 

Black  and  tan  dog;  condition,  good.  Ether  anesthesia.  The 
right  kidney  was  exposed,  and  the  artery  and  vein  clamped  for  a 
period  of  /  hour.  The  operative  recovery  was  good.  Blood  was 
present  in  the  urine  for  four  days  after  the  operation  and  albumin  in 
large  amount  throughout  the  experiment. 

January  29. 

The  dog  was  anesthetized  again,  and  the  kidney  exposed  as  be- 
fore. On  dividing  the  ureter  six  drops  of  urine  flowed  in  20  minutes. 
The  kidney  was  very  edematous  and  bound  down  by  dense  adhesions 
to  the  peritoneum  and  intestines.  The  adhesions  were  so  dense  that 
it  was  impossible  to  remove  the  kidney  without  injuring  the  in- 
testines. 

Microscopical  Examination. — Very  extensive  hemorrhage  and 
epithelial  desquamation  were  present.  In  some  places  the  glomeruli 
were  destroyed,  with  only  a  mass  of  blood  detritus  marking  where 
they  had  been.  In  other  areas  remains  of  glomeruli  were  present, 
but  no  normal  ones  were  found  in  any  part  of  the  kidney.     The 


ANEMIA  OF  THE  KIDNEYS  209 

tubules  contained  numerous  epithelial  and  hyaline  casts.  In  some 
areas  they  had  been  obliterated  by  connective  tissue  formation.  The 
desquamation  of  the  epithelial  cells  was  irregular,  being  complete 
in  some  areas  and  incomplete  in  others.  In  but  few  places  could 
marked  diffusion  of  chromatin  be  made  out.  From  the  extent  of 
the  connective  tissue  proliferation  it  seemed  that  the  kidney  must 
have  been  affected,  at  least  to  a  certain  extent,  before  the  experiment, 
and  that  the  marked  extent  of  the  changed  after  the  experiment  was 
due  in  part  to  the  previous  condition.  More  will  be  said  later  about 
the  increased  susceptibility  to  anemia  of  previously  damaged  kidneys. 


EXPERIMENT    4 

March  9,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right  kid- 
ney was  exposed,  and  both  artery  and  vein  clamped  for  /  hour.  The 
next  morning  the  urine  gave  a  positive  benzidin  reaction,  but  nega- 
tive reactions  were  obtained  on  each  of  the  following  six  days. 

March  19. 

The  dog  was  again  anesthetized,  and  the  ureter  divided.  No 
urine  flowed  from  the  ureter  while  observed  for  a  considerable  time. 
The  perirenal  adhesions  were  very  dense  and  firm.  The  kidney 
was  very  edematous  and  much  larger  than  the  other  kidney.  The 
capsule  was  thickened  and  adherent. 

Microscopical  Examination. — The  tubular  epithelium  pre- 
sented ragged  borders,  and,  in  many  places,  had  desquamated.  The 
glomeruli  presented  an  appearance  like  that  in  the  other  experiments. 
■While  round-cell  infiltration  was  present  around  the  glomeruli  it  was 
not  present  around  the  tubules.  In  many  cells  diffusion  of  nuclear 
chromatin  had  occurred,  and,  where  these  cells  were  most  numerous, 
desquamation  was  most  extensive.  The  entire  organ  was  edematous, 
but  there  was  not  much  hemorrhage.  As  a  whole,  the  condition  was 
better  than  in  the  one-hour  experiments  in  which  the  artery  alone 
was  clamped,  but  the  changes  seemed  to  be  limited  more  to  the 
parenchyma. 

EXPERIMENT    5 
February  6,  191  o. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  right 
kidney  was  exposed,  and  the  artery  and  vein  clamped  for  7^4  hours. 
A  few  seconds  after  removing  the  clamp  there  was  slight  oozing 
from  the  capsule,  and  the  color  of  the  kidney  changed  from  purple 
to  bright  red.    The  oozing  continued  until  the  end  of  the  operation. 


2IO  SURGICAL  ANEMIA  AND  RESUSCITATION 

The  operative  recovery  was  good.     The  next  morning  albumin  was 
present  in  the  urine,  and  a  positive  benzidin  reaction  was  obtained. 

February  i6. 

The  dog  was  again  anesthetized,  and  the  kidney  exposed  as  be- 
fore. No  urine  flowed  when  the  ureter  was  divided,  although  the 
observation  extended  over  a  period  of  an  hour.  The  kidney  was 
firmly  adherent,  and  could  be  removed  only  with  difificulty.  On  sec- 
tion it  was  found  to  be  very  edematous,  the  line  of  demarcation  be- 
tween cortex  and  medulla  was  not  at  all  distinct,  and  interstitial 
hemorrhages  were  present. 

Microscopical  Examination. — Extensive  desquamation  was 
present  in  all  parts  of  the  kidney.  The  glomeruli  were  hemorrhagic, 
and  generally  disintegrated,  and,  with  the  tubules,  were  surrounded 
with  round-cell  infiltration.  In  many  places  the  connective  tissue 
had  been  so  freely  proliferated  that  the  tubules  were  occluded  in 
whole  or  in  part.  In  the  patent  tubules  were  many  epithelial  casts, 
the  adherent  cells  having  largely  lost  their  structure.  Nuclear 
chromatin  was  frequently  diffused  into  the  cytoplasm.  The  tissues 
were  everywhere  very  edematous  and  stained  poorly.  Newly  formed 
blood  vessels  had  extended  from  the  thickened  capsule  into  the  kidney 
substance.  In  short  the  anemia  had  been  of  long  enough  duration  to 
destroy  most  of  the  renal  parenchyma  and  produce  interstitial  pro- 
liferation. 

EXPERIMENTS   6,   7,  AND   8 

In  these  three  experiments,  the  details  of  which  will  not  be  given, 
the  anemia  was  for  longer  periods  than  in  the  preceding  experiments 
in  this  series.  The  changes  were  in  extent  rather  than  in  quality. 
In  the  three  and  four-hour  experiments  renal  abscesses  were  caused. 

Summary 

The  only  differences  found  between  the  results  obtained  by 
clamping  the  renal  artery  alone  or  both  the  renal  artery  and 
vein  seemed  to  consist  in  the  production  of  greater  changes  in 
the  latter  case  and  also  in  greater  damage  to  the  parenchyma. 

In  both  series  of  experiments  anemia  of  over  30  minutes 
caused  permanent  parenchymatous  degeneration.  When  the 
time  was  increased  to  one  hour  the  kidney  ceased  to  secrete 
urine  and  its  functions  were  lost.     Hemorrhage  into  the  renal 


ANEMIA  OF  THE  KIDNEYS  21 1 

substance  seemed  to  depend  more  on  the  amount  the  kidney 
had  to  be  handled  in  carrying  out  the  technique  than  on 
whether  artery  alone  or  both  vein  and  artery  were  ligated. 
It  was  a  phenomenon  of  irregular  occurrence  at  all  times. 
Hemorrhage  into  the  glomeruli  was  constant  after  anemia  of 
30  minutes. 

Group  III.    Anemia  of  the  Kidney  of  Dogs  from  Which  One 
Kidney  Had  Previously  Been  Removed 

EXPERIMENT    i 

February  15,  1910. 

Ether  anesthesia.  The  dog  used  in  this  experiment  had  previ- 
ously had  his  right  kidney  removed  in  Experiment  3,  Group  I.  He 
was  in  good  condition  in  every  way  before  operation,  and  made  a 
good  immediate  recovery  after  having  his  left  kidney  exposed  and 
both  the  renal  artery  and  vein  clamped  for  50  minutes. 

February  16. 

The  dog  seemed  to  be  in  good  condition  early  in  the  morning, 
but  during  the  afternoon  he  was  found  dead  in  his  kennel.  The 
autopsy  revealed  a  double  lobar  pneumonia.  The  kidney  was  very 
edematous  and  had  interstitial  hemorrhages.  There  was  no  urine 
in  the  bladder.  The  renal  pelvis  was  filled  with  blood.  The  micro- 
scopical examination  showed  the  renal  cells  to  be  very  edematous 
and  the  tubules  to  be  filled  with  blood  corpuscles  and  detritus. 

EXPERIMENT    3 
February,  19  id. 

Ether  anesthesia.  The  dog  used  in  this  experiment  had  previ- 
ously had  his  right  kidney  removed  in  Experiment  i,  Group  I.  He 
was  in  good  condition  before  the  operation,  and  made  a  good  im- 
mediate recovery  after  having  the  remaining  kidney  exposed  and 
the  artery  alone  clamped  for  jo  minutes. 

On  the  next  morning  pressure  over  the  dog's  bladder  brought  out 
a  small  amount  of  bloody  urine,  but  no  more  urine  could  be  obtained 
after  that  one  time.  The  animal's  condition  seemed  to  be  good  for 
three  days.  He  then  became  stupid,  refused  food,  and  was  found  dead 
on  the  morning  of  the  fourth  day  after  the  operation.  The  autopsy 
revealed  an  acute  parenchymatous  nephritis  of  the  remaining  kidney, 


212  SURGICAL  ANEMIA  AND  RESUSCITATION 

with  extensive  hemorrhage  into  the  renal  substance.  The  condition, 
as  a  whole,  resembled  that  found  in  the  kidney  after  anemia  of  one 
hour  in  Group  I. 

EXPERIMENT    3 

February,  1910. 

Under  ether  anesthesia  the  remaining  kidney  of  a  dog  from 
which  one  kidney  had  previously  been  removed  was  exposed,  and  the 
renal  artery  clamped  for  jo  minutes.  The  dog  died  four  days  later 
from  total  suppression  of  urine.  The  histological  examination  re- 
vealed' changes  identical  with  those  found  in  the  other  two  experi- 
ments in  this  group. 

In  addition  to  these  three  30-minute  experiments  three 
other  dogs,  which  had  recovered  after  removal  of  one  kidney, 
had  their  remaining  kidney  rendered  anemic  for  periods  of 
20  minutes  each.  All  three  died  with  suppression  of  urine,  the 
histological  changes  being  the  same,  only  of  less  degree. 

Summary 

From  these  six  experiments  it  was  evident  that  a  kidney 
that  is  doing  an  unusual  amount  of  work  cannot  endure 
anemia  so  well  as  a  kidney  which  is  working  under  a  normal 
load.  It  might  be  argued  that  suppression  of  urine  in  these 
last  experiments  was  due  to  the  operative  technique  alone,  but 
this  argument  does  not  hold,  because,  when  done  carefully 
under  proper  conditions,  almost  all  dogs  survive  having  one 
kidney  removed.  The  anemia  must,  therefore,  have  been 
the  harmful  factor  in  causing  the  fatal  results.  Moreover, 
dogs  in  which  one  out  of  a  pair  of  kidneys  was  rendered 
anemic  did  not  have  that  kidney  permanently  injured  in  the 
same  length  of  time. 

Summary  of  All  Experiments 

From  all  of  the  experiments  in  the  three  groups,  as  well  as 
from  evidence  not  reported  here,  the  sequence  of  the  changes 


ANEMIA  OF  THE  KIDNEYS  213 

following  interference  with  the  arterial  blood  supply  to  the 
point  of  complete  occlusion  is  roughly  as  follows,  it  being 
recognized  that  the  chronological  variation  is  not  exact  on 
account  of  individual  differences  and  other  factors  not  clearly 
understood : 

1.  Edema  of  (a)  parenchyma  and  (b)  of  interstitial  sub- 
stance. 

2.  Exhaustion  of  the  cytoplasm  of  the  epithelial  cells,  and, 
later,  liberation  of  the  nuclear  chromatin  and  its  distribution 
through  the  cytoplasm. 

3.  Simultaneously  with  the  exhaustion  of  the  cytoplasm, 
hemorrhage  from  the  glomeruli  and  round-cell  infiltration 
around  the  glomeruli  and  tubules. 

4.  Death  and  desquamation  of  the  epithelial  cells. 

5.  Changes  in  the  structure  of  the  glomeruli. 

6.  Diminution  in  and  final  cessation  of  the  renal  func- 
tions. 

7.  Proliferation  of  connective  tissue,  beginning  in  the 
portions  of  the -kidney  less  richly  supplied  with  blood.  This 
proliferation  is  more  or  less  independent  of  all  of  the  other 
changes  as  regards  time  of  onset.  It  seems  to  be  an  effort 
toward  repair. 

8.  Occlusion  of  both  tubules  and  glomeruli  followed  by 
epithelial  regeneration  in  which  the  new  cells  bear  little  re- 
semblance to  the  old. 

9.  Beginning  independently  of  the  other  changes  and 
continuing  after  the  functional  death  of  the  kidney,  is  the  in- 
growth of  capillaries  from  the  capsule  to  the  cortex,  and  even 
into  the  medulla  when  the  renal  artery  has  been  completely  oc- 
cluded. 

10.  Thickening  and  adherence  of  the  capsule  with  peri- 
capsular  adhesions.  These  changes  may  begin  early,  but,  as 
a  rule,  the  longer  the  anemia  the  more  they  are  marked. 


214  SURGICAL  ANEMIA  AND  RESUSCITATION 

Conclusions 

From  the  foregoing  facts  it  is  evident  that  the  following 
conclusions  may  be  drawn  regarding  the  changes  caused  by 
complete  obstruction  of  the  arterial  supply  of  the  kidney: 

1.  The  gravity  of  the  lesions  produced  is  in  direct  pro- 
portion to  the  duration  of  the  anemia. 

2.  The  changes  which  occur  after  prolonged  anemia  vary 
in  intensity  rather  than  in  variety. 

3.  More  severe  changes  are  produced  by  occluding  the 
venous  circulation  as  well  as  the  arterial  circulation. 

4.  Whether  artery  alone  or  artery  and  vein  are  occluded, 
anemia  of  over  30  minutes  causes  permanent  changes  in  the 
renal  structure. 

5.  Anemia  of  one  hour  causes  almost  total  loss  of  renal 
function,  while  anemia  of  three  hours  (or  less)  totally  de- 
stroys it. 

6.  After  anemia  of  between  30  minutes  and  one  hour 
enough  functional  power  may  persist  to  make  the  organ  useful. 

7.  Anemia  of  less  than  30  minutes  causes  no  histological 
changes  of  consequence.  Hence,  while  the  human  kidney  may 
be  more  resistant  than  that  of  the  dog,  it  would  seem  that  one- 
half  hour  should  be  the  maximum  time  for  the  occlusion  of 
circulation  in  the  human  kidney. 

8.  Before  interfering  with  the  circulation  in  one  human 
kidney  it  is  as  important  to  ascertain  the  functional  activity 
of  the  other  kidney  as  it  is  when  one  kidney  is  to  be  removed. 

n.    ANEMIA  OF  THE  SPLEEN 

In  the  following  experiments  the  spleens  of  dogs  were 
made  anemic  by  occluding  the  arterial  circulation  by  means  of 
rubber-protected  clamps  for  periods  of  time  varying  from 
thirty  minutes  to  four  hours. 


ANEMIA  OF  THE  SPLEEN  21$ 

EXPERIMENT    i 

February  7,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  Under  careful 
asepsis  the  abdomen  was  opened,  and  the  splenic  artery  clamped  for 
50  minutes.  The  dog  was  in  good  condition  at  the  end  of  the  opera- 
tion.    The  spleen  showed  no  gross  evidence  of  change. 

February  8. 

No  ill  effects  from  operation  were  visible,  the  dog  eating  and 
drinking  heartily  and  playing  around  the  kennel. 

February  21. 

The  dog  was  again  anesthetized,  and  the  spleen  exposed.  A  few 
adhesions  were  found  where  the  clamp  had  been  applied,  but  other- 
wise the  spleen  appeared  to  be  normal.  The  artery  and  vein  were 
ligated  and  the  spleen  removed.  It  was  not  enlarged.  No  macro- 
scopical  changes  could  be  made  out  from  the  cut  surface.  The  dog 
was  allowed  to  recover,  and,  after  living  for  a  week  in  good  condi- 
tion, was  used  in  a  resuscitation  experiment,  and  died. 

Microscopical  Examination. — The  tunica  albuginea  was  thicker 
than  normal,  and  the  blood  vessels  running  through  it  had  thickened 
walls.  The  thickening  was  continued  into  the  trabeculae.  The 
muscle  fibers  were  apparently  undisturbed.  In  no  place  was  hemor- 
rhage or  round-cell  infiltration  found.  The  splenic  pulp  showed  more 
breaking  down  than  was  to  have  been  expected.  In  the  Malpighian 
corpuscles  evidences  of  proliferation  were  present.  On  the  whole, 
but  little  change  of  consequence  had  taken  place,  and,  in  fact,  no 
more  than  might  have  been  consistent  with  healthy  variation  from 
the  normal. 

EXPERIMENT    2 

February  8,  1910. 

Mongrel  bitch ;  condition,  good.  Ether  anesthesia.  Under  asep- 
tic precautions  the  abdomen  was  opened,  and  the  splenic  artery 
clamped  for  ^5  minutes.  The  pulse  rate  had  risen  from  87  to  132 
beats,  and  the  blood  pressure  fallen  from  120  to  80  mm.  of  mercury 
at  the  end  of  the  operation.     The  general  condition  was  good. 

February  9. 

Condition,  good.    Pulse,  no;  blood-pressure,  no  mm. 

February  ii. 

Condition,  good.    Pulse,  no;  blood-pressure,  no  mm. 

February  15. 

Condition,  good.    Pulse,  no;  blood-pressure,  no  mm. 


21 6  SURGICAL  ANEMIA  AND  RESUSCITATION 

February  21, 

The  bitch  was  again  anesthetized  and  the  spleen  exposed.  The 
spleen  was  larger  and  softer  than  when  clamped.  There  were  numer- 
ous adhesions  about  the  blood  vessels  and  the  upper  pole.  No  hemor- 
rhage had  occurred  externally.  The  vessels  were  ligated,  the  spleen 
removed,  and  the  bitch  allowed  to  recover.  She  showed  no  after- 
effects.    The  blood-pressure  became  normal  in  three  days. 

Microscopical  Examination. — The  thickening  of  the  tunica  al- 
buginea,  noted  in  the  previous  experiment,  was  still  more  marked 
in  this  one.  There  was  considerable  hyperplasia  of  the  muscle  fibers, 
both  in  the  tunica  and  the  trabeculae.  As  the  sections  had  not  been 
stained  to  show  the  elastic  tissue  it  is  impossible  to  say  whether  it 
was  affected  or  not.  The  blood  vessels  had  thickened  walls.  In  some 
places  there  had  been  hemorrhages  into  the  trabeculae,  as  well  as 
round-cell  infiltration.  The  proliferation  of  the  connective  tissue 
elements  along  the  trabeculae  was  apparent,  and  most  markedly  so 
near  the  hilum.  The  areas  of  pulp  had  been  reduced  in  size,  owing  to 
this  proliferation.  The  pulp  contained  many  newly  formed  cells, 
which  were  larger  than  the  others,  and  stained  more  intensely. 
The  leukocytes  showed  all  degrees  of  degeneration,  and  many  of 
them  did  not  stain  at  all.  In  ^he  Malpighian  corpuscles  hemorrhages 
were  present,  which,  in  many  areas,  obliterated  all  traces  of  structure. 

The  principal  changes,  therefore,  consisted  in  increase  in  the 
connective  tissue  elements,  a  corresponding  decrease  in  the  pulp, 
round-cell  infiltration,  and  intercorpuscular  hemorrhages.  Conse- 
quently anemia  of  40  minutes  was  sufficient  to  cause  the  formation 
of  permanent  lesions. 

EXPERIMENT    3 

February  15,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  Under  aseptic 
precautions  the  abdomen  was  opened,  the  spleen  exposed,  and  the 
splenic  artery  clamped  for  /  hour.  The  blood-pressure  fell  from  115 
to  85  mm.  during  the  operation.     The  operative  recovery  was  good 

March  9. 

The  dog's  condition  had  been  excellent.  He  was  again  anes- 
thetized and  the  spleen  exposed.  It  was  found  to  be  so  densely  ad- 
herent that  it  was  impossible  to  remove  it  without  killing  the  dog. 

Microscopical  Examination. — The  tunica  albuginea  was  very 
much  thickened.  The  muscle  fibers  were  markedly  hypertrophied. 
Throughout  the  connective  tissue  framework  there  had  been  exten- 
sive hemorrhage  and  round-cell  infiltration.     The  connective  tissue 


ANEMIA  OF  THE  SPLEEN  217 

around  all  of  the  blood  vessels  was  very  much  thickened,  so  that  the 
pulp  had  been  so  encroached  upon  as  to  be  entirely  obliterated  in 
places. 

Around  certain  blood  vessels  the  round-cell  infiltration  had  been 
so  extreme  as  to  obliterate  the  trabeculae.  The  Malpighian  cor- 
puscles varied.  In  some  there  had  been  extensive  hemorrhage, 
while  in  others  the  proliferation  of  the  lymphoid  tissue  had  been  so 
extreme  as  to  efface  all  else.  The  number  of  large,  deeply  staining 
cells  with  large  vesicular  nuclei  was  greater  than  in  the  preced- 
ing experiment,  and  in  some  areas  these  cells  predominated.  Few  or 
none  of  these  cells  can  be  found  in  a  normal  specimen. 


EXPERIMENT    4 

March  16,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  Under  aseptic 
precautions  the  abdomen  was  opened,  the  spleen  exposed,  and  the 
splenic  pedicle  clamped  for  /^  hours.  The  operative  recovery  was 
good. 

Microscopical  Examination. — The  tunica  albuginea  was 
greatly  thickened  and  edematous.  The  blood-vessel  walls  were  also 
thickened,  and  there  had  been  considerable  hemorrhage  into  the  tis- 
sues. The  amount  of  connective  tissue  throughout  was  very  great, 
so  that  the  individual  areas  of  splenic  pulp  had  been  obliterated. 
With  this  there  was  a  correspondingly  marked  round-cell  infiltration. 
The  Malpighian  corpuscles  appeared  as  masses  of  red  cells,  their 
structure  being  entirely  obliterated.  Everywhere  there  were  large 
vesicular  cells  with  irregularly  stained  nuclei,  many  of  them  broken 
down  with  the  chromatin  diffused  through  the  cytoplasm.  Some 
areas  showed  nothing  but  connective  tissue  and  round-cell  infiltra- 
tion. The  entire  tissue  was  very  edematous,  and  was  filled  with 
broken  down   masses  of  leukocytes. 


EXPERIMENT    5 

March  17,  1910. 

Mongrel  dog;  condition,  good.  Ether  anesthesia.  The  splenic 
artery  was  clamped  for  2  hours  in  the  usual  way.  The  dog  was  in 
good  condition  at  the  end  of  the  operation,  but  the  color  did  not 
return  to  the  spleen  so  rapidly  as  it  did  during  the  other  experiments, 
and  there  was  considerable  oozing  around  the  place  of  application  of 
the  clamp. 


2l8  SURGICAL  ANEMIA  AND  RESUSCITATION 

March  i8. 

The  dog  was  found  dead.  At  the  autopsy  the  abdomen  was 
found  to  be  filled  with  blood,  the  spleen  having  ruptured  near  the 
place  of  application  of  the  clamp.     Sections  were  not  examined. 

EXPERIMENT    6 

March  i8,  1910. 

Black  and  tan  bitch;  condition,  good.  Ether  anesthesia.  Under 
aseptic  precautions  the  spleen  was  exposed,  and  the  splenic  artery 
clamped  for  2  hours.  When  the  clamp  was  removed  there  was  some 
oozing  from  the  place  of  application.  This  soon  stopped,  and  the 
bitch  was  returned  to  the  kennel  in  good  condition. 

April  8. 

The  bitch  had  remained  in  good  condition.  She  was  again  anes- 
thetized and  such  a  dense  mass  of  adhesions  found  around  the  spleen 
that  it  could  be  removed  only  with  great  difficulty.  The  organ,  as  a 
whole,  was  much  smaller  and  firmer  than  normal,  and  felt  like  a 
mass  of  fibrous  tissue.    The  artery  was  occluded  with  a  thrombus. 

Microscopical  Examination. — No  normal  splenic  tissue  was 
present.  From  the  tunica  albuginea  dense  adhesions  extended  into 
the  surrounding  tissue,  and  in  these  adhesions  were  many  capillaries, 
but  the  blood  vessels  in  the  trabeculae  were  occluded.  The  oblitera- 
tion of  the  pulp  was  complete.  In  one  area  there  was  a  large  in- 
farct which  had  not  stained  at  all. 

This  experiment  can  hardly  be  considered  as  one  which  shows 
the  effect  of  anemia  for  two  hours,  on  account  of  the  formation 
of  the  thrombus  in  the  splenic  artery.  Most  of  the  blood  supply 
came  from  the  capillaries  in  the  adhesions.  The  experiment  is  of 
value,  however,  as  showing  that  thrombosis  may  readily  occur  if  too 
long  or  too  great  pressure  be  applied  to  a  temporarily  compressed 
artery. 

EXPERIMENT    7 
March  18,  1910. 

Bulldog;  condition,  good.  Ether  anesthesia.  Under  aseptic  pre- 
cautions the  spleen  was  exposed,  and  the  splenic  vessels  clamped  for 
syz  hours.  The  dog  was  in  good  condition  at  the  end  of  the  opera- 
tion, but  was  found  dead  the  next  morning  with  extensive  hemor- 
rhage from  rupture  of  the  spleen.     The  spleen  was  much  enlarged. 

EXPERIMENTS   8,  9,  AND    10 

In  these  experiments  the  splenic  artery  was  clamped  for  periods 


ANEMIA  OF  THE  SPLEEN  219 

of  3,  4,  and  5  hours.  In  each  instance  the  animals  went  through 
the  operation  well,  but  were  found  dead  twenty- four  hours  later  from 
hemorrhage  from  rupture  of  the  spleen.  No  changes  were  found  in 
the  organ  except  marked  edema,  as  there  had  not  been  time  for  tis- 
sue degeneration  to  develop. 

Summary 

The  chief  changes  caused  by  anemia  of  the  spleen  were 
marked  proliferation  of  all  of  the  connective  tissue  elements 
in  the  tunica  albuginea,  around  the  blood  vessels,  and  in  the 
trabeculse,  and  a  gradual  compensating  reduction  of  the  splenic 
pulp,  w^ith  its  final  obliteration.  In  the  experiments  in  which 
the  anemia  was  of  short  duration  there  was  some  hyper- 
trophy of  the  muscle  fibers  and  formation  of  large  cells,  which 
tended  to  break  down  and  to  discharge  their  nuclear  chromatin 
into  the  cytoplasm.  The  chief  changes  in  the  Malpighian  cor- 
puscles consisted  of  hemorrhage  and  proliferation  of  the  lym- 
phoid tissue. 

The  only  constant  post-operative  clinical  change  noted  was 
a  fall  in  the  blood-pressure  which  persisted  for  several  days. 
This  fall  averaged  30  millimeters  of  mercury.  In  experiments 
in  which  the  clamp  was  applied  for  more  than  two  hours  rup- 
ture of  the  spleen  always  occurred.  Whether  this  might 
have  been  obviated  by  permitting  a  gradual  return  of  the  cir- 
culation is  not  known.  No  changes  were  noted  in  the  his- 
tological structure  when  the  anemia  was  of  less  duration  than 
forty-five  minutes,  but  in  longer  periods  permanent  damage 
was  done. 


CHAPTER  X 

RESUSCITATION  OF  THE  BODY  AS  A  WHOLE 

GENERAL  CONSIDERATIONS 

The  popular  conception  of  death  does  not  permit  of  its 
being  regarded  as  anything  but  absolute  in  character.  This  is 
really  the  only  accurate  conception.  For  scientific  purposes, 
however,  it  is  convenient,  if  not  essential,  to  divide  the  process 
of  dying  into  three  stages.  It  should  be  recognized  that  each 
stage  merges  into  the  others — hard  and  fast  lines  between 
them  cannot  be  drawn.  In  the  opinion  of  the  author  these 
stages  cannot  be  designated  better  than  by  the  terms  first  em- 
ployed, so  far  as  is  known,  by  d'Halluin,  i.  e.,  apparent  death, 
relative  death,  and  absolute  death. 

In  apparent  death,  as  the  term  implies,  to  all  outward 
appearances  the  vital  functions  have  ceased.  Respiration  is 
present,  but  at  such  a  low  ebb  that  special  methods  of  exam- 
ination are  needed  to  detect  it.  It  is  sufficient  to  maintain  life, 
and  life  may  persist  for  long  periods  of  time.  The  heart  beats 
feebly ;  possibly  so  feebly  that  its  action  can  be  detected  only 
with  the  stethoscope.  Motor  activity  is  inhibited.  The  skin 
is  pale  and  cold.  The  eyes  may  be  either  closed  or  open,  but 
are  unseeing  and  motionless.  Seldom  is  there  sufficient  relax- 
ation of  the  sphincters  to  cause  incontinence.  Unconscious- 
ness may  be  either  present  or  absent. 

Relative  death  may  be  defined  as  the  condition  of  the  body 
during  the  few  minutes  between  entire  cessation  of  cardiac  and 
respiratory  activity  and  absolute  death.     In  the  early  stages 

220 


RESUSCITATION  OF  THE  RESPIRATORY  APPARATUS        221 

of  relative  death  complete  resuscitation  is  possible.  In  the 
later  stages  resuscitation  is  possible,  but  there  is  permanent 
loss  of  certain  higher  functions.  In  still  later  stages  auto- 
maticity  of  cardiac  and  even  respiratory  action  may  be  re- 
sumed, but  consciousness  may  never  be  regained. 

At  first  thought,  it  would  seem  that  immediately  after 
cessation  of  the  heart  action  the  stagnant  blood  would  be  of 
little  use  to  the  surrounding  cells.  The  probability  is,  how- 
ever, that  stagnant  blood  contains  enough  absorbable  oxygen 
to  permit  the  tissues  to  undergo  the  stage  of  relative  death. 
It  is  hardly  credible  that  interchange  of  oxygen  and  carbonic 
oxid  should  cease  the  instant  the  blood  stops  flowing  past  the 
cells  in  the  delicate-walled  capillaries,  and  while  the  inter- 
change goes  on  the  individual  cells  must  benefit  by  it,  even  if 
in  rapidly  diminishing  degree.  There  is  every  reason  to  be- 
lieve that  the  stage  of  relative  death  depends  almost  wholly  on 
this  interchange,  at  least  for  the  central  nervous  system. 

Absolute  death  is  that  condition  in  which  resuscitation 
of  the  body  as  a  whole  is  impossible.  The  phrase  "as  a  whole" 
is  used  advisedly,  as  different  parts  of  the  body,  as  has  been 
shown  elsewhere  in  this  book,  may  be  resuscitated  hours  or 
even  weeks  after  absolute  death. 

The  determination  of  absolute  death  is  unimportant,  since 
in  cases  of  apparently  suspended  animation  time  is  so  valuable 
that  even  a  second  should  not  be  used  in  any  but  resuscitative 
measures.  For  this  reason  it  is  well  to  proceed  at  once  to  a 
discussion  of  various  methods  of  resuscitation. 

fRESUSCITATION   OF  THE  RESPIRATORY  APPARATUS 

Artificial  Respiration 

Any  method  of  artificial  respiration  should  aim  to  repro- 
duce normal  respiration  as  nearly  as  possible.     Careful  ex- 


222  SURGICAL  ANEMIA  AND  RESUSCITATION 

perimentation  has  shown  that  what  must  be  considered  nor- 
mal respiration  varies  within  wide  Hmits  in  different  indi- 
viduals. As  determined  by  Vierordt,  a  normal  average  rate 
of  exchange  of  air  per  minute  is  about  5,300  cubic  centi- 
meters. This  exchange,  often  called  the  flow  of  the  tidal  air, 
must  not  only  be  sufficient  per  given  respiration,  but  the  num- 
ber of  respirations  per  given  unit  of  time  must  be  sufficient. 
Also  a  test  of  the  efficiency  of  any  method  of  artificial  res- 
piration must  show  not  only  that  amount  and  rate  can  be 
maintained,  but  also  that  about  5,300  cubic  centimeters  at  least 
can  be  made  to  enter  the  lungs  per  minute.  \ 

It  is  beyond  the  province  of  this  book  to  discuss  the  his- 
torical side  of  artificial  respiration,  but  it  seems  to  have  been 
first  used  largely  to  resuscitate  the  apparently  drowned.  In 
his  recent  Hunterian  Lectures  Keith  gives  a  most  interesting 
historical  review  of  the  subject.  He  mentions  the  facts  that 
in  Amsterdam  in  1767  a  society  was  founded  for  the  resusci- 
tation of  the  drowned  or  apparently  dead,  while  in  1774  the 
Royal  Humane  Society  of  England  was  founded  with  the 
same  objects  as  part  of  its  purpose.  As  far  as  can  be  ascer- 
tained, however,  it  was  not  recognized  until  within  recent 
years  that  artificial  respiration  is  really  the  most  important  of 
the  different  measures  advocated. 

Of  the  best  known  methods  for  producing  artificial  respi- 
ration those  of  Silvester  (with  patient  in  supine  posture),  of 
Howard  (with  patient  in  prone  posture),  of  Marshall  Hall 
(with  patient  alternately  in  prone  and  lateral  posture), 
Brosch's  modification  of  the  Silvester  method  (the  modifica- 
tion consisting  essentially  in  a  further  modification  of  the 
movement  of  the  arms  backward  over  the  head  with  over- 
extension of  the  upper  part  of  the  spine),  and  the  method  of 
Schafer  (with  patient  in  prone  posture),  need  no  further 
comment   with   the   exception   of    the    Brosch-Silvester   and 


RESUSCITATION  OF  THE  RESPIRATORY  APPARATUS        223 

Schafer's  methods.  Keith  states  that  in  1908  Meyer  and 
Loewy  tested  the  Brosch-Silvester  method  by  Schafer's  plan 
and  found  that  they  could  get  a  respiratory  exchange  of 
from  7,000  to  16,000  c.  c.  per  minute,  as  against  5,850  by 
Schafer's  method.  This  claim  makes  the  respiratory  ex- 
change greater  than  that  obtainable  by  any  other  method. 
Schafer  compared  his  own  method  with  the  other  methods 
just  mentioned,  with  the  exception  of  the  Brosch-Silvester, 
and  found  that  of  these  it  gave  the  greatest  air  exchange. 
His  findings  are  expressed  in  the  table.  No  one  of  these 
methods,  however,  can  be  said  to  be  preeminently  the  best, 
because  no  one  method  is  applicable  to  all  situations  under 
which  artificial  respiration  has  to  be  given,  j 

Schafer's  Table  Showing  the  Relative  EIHciency  of  Methods 
of  Giving  Artificial  Respiration 


Mode  of  Respiration 

Number  per 
Minute 

Air  Exctiange 
Per  Respiration 

Air  Exchange 
Per  Minute 

Natural 

13 
13 
13 
13 
13 

450  C.  C. 
I7S  c.  C. 
310  c.  C. 
254  c.  c. 
520  c.  c. 

5,850  C.  C. 
2,280  c.  c. 

Silvester 

Howard 

4,030  c.  c. 
3,300  c.  c. 
6,760  c.  c. 

Marshall  Hall 

Schafer 

Statistics. — Age  of  subjects,  23.  Height,  S  ft.  7^^  in.  Chest  at  mammary 
line,  38  in.  Weight,  10  st.  i^  lbs.  Vital  capacity,  6,760  c.c.  Pressure  exerted 
in  performing  respiration,  60  lbs. 

'  In  1908  the  Fifth  Resuscitation  Committee  appointed  by 
the  Royal  Society  of  Medicine  recommended  that  the  Schafer 
method  of  giying  artificial  respiration  be  adopted  as  prefer- 
able to  that  of  either  Marshall  Hall  or  Silvester.  It  does  not 
follow  necessarily  that  this  method  is  the  most  efficacious  or 
that  perfection  has  been  reached,  but,  on  account  of  the  sim- 


224  SURGICAL  ANEMIA  AND  RESUSCITATION 

plicity  and  ease  of  application  of  the  technique,  the  greater 
exchange  of  air  than  by  any  other  method  except  the  Brosch- 
Silvester,  the  postural  drainage,  and  the  prevention  of  the 
tongue  from  falling  back  in  drowning  cases,  it  is,  at  the  pres- 
ent time,  the  method  of  choice.  Keith,  who  was  a  member  of 
this  committee,  does  not  regard  it  as  being  as  efficient  as  the 
Silvester  method  when  the  latter  is  properly  carried  out,  but 
he  would  advise  its  use  unless  the  proper  execution  of  the 
Silvester  method  could  be  guaranteed^ 
,    Schafer's  description  of  his  method  is  as  follows : 

"The  subject,  whether  a  drowned  person  or  not,  is  al- 
lowed to  lie  prone,  i.  e.,  face  downward,  no  preliminary 
manipulation  of  the  tongue  being  required.  The  operator 
kneels  or  squats  either  across  or  on  one  side  of  the  subject, 
facing  the  head,  and  places  his  hands  close  together  flat  upon 
the  back  of  the  subject  over  the  loins,  the  fingers  extending 
over  the  lowest  ribs.  By  now.leaning  forward  upon  the  hands, 
keeping  the  elbows  extended,  the  weight  of  the  operator's 
body  is  brought  to  bear  upon  the  subject,  and  this  not  only 
compresses  the  lower  part  of  the.thorax,  but  also  the  abdomen 
against  the.  ground,  the  pressure  being  fairly  equally  dis- 
tributed. The  result  of  this  is  that  not  only  is  the  thorax 
diminished  in  extent  from  before  back,  but,  owing  to  the 
pressure  which  is  communicated  to  the  abdomen,  the  viscera 
are  compressed  and  tend  to  force  the  diaphragm  up,  so  that 
the  thorax  is  diminished  in  capacity  from  above  .down.  This 
is,  no  doubt,  the  reason  why  the  pressure  method  when  ap- 
plied in  the  prone  position  is  more  effective  than  when  applied, 
as  by  Howard,  in  the  supine  position.  The  pressure  is  applied 
not  violently,  but  gradually,  during  about  three  seconds,  and 
is  then  released  by  the  operator  swinging  his  body  back,  but 
without  removing  his  hands.     The  elasticity  of  the  chest  and 


RESUSCITATION  OF  THE  RESPIRATORY  APPARATUS        225 

abdomen  causes  these  to  resume  their  original  dimensions  and 
air  passes  in  through  the  trachea.  After  two  seconds  the 
process  is  again  commenced,  and  is  continued  in  the  same 
way,  the  operator  swinging  his  body  forward  and  backward 
once  every  five  seconds,  or  about  twelve  times  a  minute, 
without  any  violent  effort  and  with  the  least  possible  exertion. 
This  last  condition,  viz.,  the  absence  of  muscular  exertion, 
other  than  that  Involved  in  swinging  forward  and  backward, 
renders  it  possible  to  continue  the  process  without  fatigue  for 
an  indefinite  time.  It  can  further  be  carried  out  unaided  by 
a  woman  almost  as  well  as  a  man,  by  children  upon  children; 
it  hardly  requires  to  be  taught — a  simple  demonstration  suf- 
ficiently teaches  it  to  a  large  audience.  Its  advantages  in 
drowning  cases  over  any  other  method  which  involves  the 
supine  .position  are  sufficiently  obvious — for  with  it  there  is 
no  risk  of  obstruction  by  water  or  mucus  or  the  contents  of 
the  stomach  which  cannot  accumulate  in  the  throat  but  must 
come  away  by  the  mouth;  and  the  tongue,  in  place  of  falling 
back,  as  in  the  supine  position,  falls  forward,  and  is  unable  to 
produce  obstruction." 

Resuscitation  of  the  respiratory  apparatus  Is  essentially  a 
matter  of  keeping  the  respiratory  centers  from  becoming  ane- 
mic or  of  restoring  to  them  a  normal  blood  supply  if  they  are 
already  anemic. 

"Artificial  Respiration"  Without  Movement  of  the  Thorax. 
— In  1905,  under  the  title  "Concerning  Artificial  Respiration 
Through  Ventilation  of  the  Trachea,"  H.  Hirsch,  in  his  inau- 
gural dissertation,  describes  a  method  of  keeping  an  animal 
alive  by  supplying  oxygen  to  the  lungs  under  pressure  without 
going  through  the  ordinary  means  of  giving  artificial  respira- 
tion. He  demonstrated  that  a  dog  could  be  kept  alive  for 
hours  by  this  means,  all  voluntary  muscular  effort  being  inhib- 


226  SURGICAL  ANEMIA  AND  RESUSCITATION 

ited  by  means  of  curare.  He  also  demonstrated  that  .atmos- 
pheric air  similarly  supplied  would  not  keep  an  animal  alive. 
Hirsch's  method  was  to  use  a  Volhard  tracheal  tube,  in- 
troducing it  into  the  trachea,  inflating  the  little  rubber  bag 
with  which  the  tube  is  surrounded  (thus  making  an  airtight 
connection  between  the  tube  and  the  trachea),  and  then  mea- 
suring the  pressure  with  which  the  oxygen  was  introduced. 
The  Volhard  tube  consists  of  one  glass,  hard  rubber,  or  cel- 
luloid tube  within  another,  the  outer  mantle,  or  efferent  tube, 
being  perforated  on  its  sides  for  a  short  distance  up  from  the 
bottom,  and  the  inner,  or  afferent,  tube  being  open  at  the  end, 
the  stream  of  oxygen  can  enter  the  trachea  through  the  inner 
tube,  while  the  oxidized  air  passes  out  through  the  outer  one. 
Ten  centimeters  from  the  lower  end  of  the  outer  tube  a  small 
rubber  bag  is  placed  which  can  be  inflated  through  a  small 
rubber  tube.  The  pressure  which  the  efferent  stream  exerts 
can  be  measured  by  connecting  the  outer  tube  with  a  ma- 
nometer, and  counterpressure  to  prevent  too  rapid  exhalation  is 
thus  obtained.  For  the  afferent  stream  Hirsch  used  a  pressure 
of  60  centimeters  of  water.  The  principle  of  this  method  has 
been  recently  elaborated  by  Meltzer  and  Auer  in  the  Rocke- 
feller Institute  and  has  been  used  clinically  with  notable  suc- 
cess by  Elsberg. 

f RESUSCITATION    OF    THE    CIRCULATORY    APPARATUS 

Methods  Commonly  in  Use 

'  General  Considerations. — Kuliabko,  d'Halluin,  Stewart, 
Sollman,  and  many  others  have  demonstrated  repeatedly  that 
the  isolated  heart  may  be  made  to  beat  for  hours  by  perfusing 
it  with  different  solutions,  notably  Locke's.  Moreover,  they 
have  shown  also  that  hearts  from  animals  which  have  been 
killed  may  be  removed  from  the  body  and  made  to  beat  again 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS        227 

after  as  long  a  time  of  inactivity  as  12  hours,  24  hours,  3  days, 
and  even  5  days  (Kuhabko).  In  experimenting  with  the 
hearts  of  children  dying  from  pneumonia  Kuliabko  succeeded 
in  reanimating  at  least  certain  parts  of  the  heart  twenty  and 
thirty  hours  after  death.  These  facts  demonstrate  that,  up 
to  a  certain  extent,  the  heart  is  an  organ  whose  action  is  in- 
dependent of  the  central  nervous  system.  When  an  animal  is 
asphyxiated  the  respiratory  action  almost  always  stops  first, 
then  the  cardiac,  and,  finally,  the  cerebral.  However,  if  arti- 
ficial respiration  be  supplied  the  heart  will  beat  for  a  long 
time,  even  when  the  nervous  functions  are  not  resumed.  The 
author  has  seen  the  heart  continue  to  beat  rhythmically  for  12 
hours  in  a  decapitated  overtrans fused  dog.  The  continued 
heart  action  is  more  dependent  on  the  presence  of  calcium 
salts  in  whatever  fluid  is  passing  through  it  than  it  is  on  stim- 
ulation from  the  nervous  systeixL  J 

Reanimation  of  the  heart  after  a  long  interval  has  elapsed 
since  its  removal  from  the  body  does  not  mean  necessarily 
that  it  will  contract  in  a  coordinated  manner  as  it  does  during 
life — there  may  be  contraction  of  the  auricles  without  con- 
traction of  the  ventricles.  In  over  one  hundred  cases  tab- 
ulated by  d'Halluin  from  his  experiments,  mostly  on  the  hearts 
of  dogs,  there  is  no  instance  recorded  in  which  the  reverse  of 
this  statement  was  true,  i.  e.,  that  the  ventricles  ever  con- 
tracted without  the  auricles  doing  likewise.  In  4  instances  he 
obtained  rhythmic  beating  of  both  auricles  and  ventricles  be- 
tween 16  and  17  hours  after  death.  The  longest  time  he  re- 
cords after  which  he  obtained  rhythmic  auricular  action,  but 
no  ventricular  action,  was  42  hours.  In  one  case  he  records 
"tremulations"  of  the  auricles,  in  16  of  the  ventricles,  and  in 
one  case  fibrillary  tremors  of  the  ventricles.  To  these  cases 
might  be  added  many  similar  observations  by  the  author. 
When  death  occurs,  how  long  will  the  heart  continue  to 


228  SURGICAL  ANEMIA  AND  RESUSCITATION 

beat  after  respiration  ceases?  In  dogs  killed  by  clamping  the 
trachea,  by  illuminating  gas  poisoning,  by  chloroform,  or  by 
ether,  the  author  has  made  repeated  observations  in  which  the 
heart  has  continued  to  beat  from  one  to  three  or  even  four 
minutes,  both  respiration  and  carotid  pulse  being  recorded  on 
the  same  drum.  In  pure  asphyxia  he  has  seen  the  heart  beat 
for  6  minutes  with  sufficient  strength  to  make  the  blood  circu- 
late, while  contractions  have  continued  for  a  much  longer  timej 

According  to  d'Halluin,  Vulpian  observed  fibrillary  con- 
traction of  the  right  auricle  of  a  dog  93  hours  after  death, 
while  Sailer  and  Reid  observed  heart  beats,  also  in  a  dog,  for 
72  minutes.  D'Halluin  himself  observed  rhythmic  contrac- 
tions in  the  auricles  and  right  ventricle  of  a  cat  for  more  than 
an  hour  "even  though  the  heart  had  been  withdrawn  from 
the  chest  and  placed  on  an  extemporaneously  constructed 
cardiograph." 

In  a  recent  observation  made  by  Dr.  F.  W.  Hitchings  in 
the  case  of  a  patient  with  uremic  convulsions,  the  heart  at  one 
time  stopped  beating  effectively,  as  was  determined  by  the 
absence  of  heart  sounds  (stethoscope)  and  by  the  cessation  of 
all  radial  pulsation,  for  three  and  one-half  minutes  after  the 
complete  cessation  of  respiration.  At  the  end  of  that  time  it 
began  to  beat  again,  at  first  very  feebly,  and  respiration  soon 
recommenced  without  the  use  of  any  measures  to  restore  it. 
This  observation  was  made  near  the  end  of  the  series  of  con- 
vulsions, and  just  after  the  last  severe  convulsion,  death  occur- 
ring six  hours  later. 

The  rhythmic  contraction  of  part  of  the  heart  cannot  be 
regarded  as  sufficient  to  furnish  efficient  circulation,  and  it  is 
doubtful  if  efficient  contraction  persists  on  the  average  longer 
than  for  from  three  to  five  minutes.  In  all  cases  duration  of 
time  between  the  final  cessation  of  the  heart  beat  and  its 
restoration  should  be  taken  as  the  criterion  of  temporary  sus- 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS       229 

pension  of  animation,  rather  than  the  duration  of  time  from 
the  cessation  of  respiration.  Without  doubt  in  many  cases 
of  accident  the  heart  has  beat  feebly,  to  be  sure,  but  with 
sufficient  force  to  supply  the  brain  with  enough  blood  to  sus- 
tain its  functions,  when,  in  the  hurry  and  excitement,  the  ob- 
servers could  not  detect  any  action  and  have  believed  that 
it  was  absent.  It  is  in  such  cases  as  these  that  artificial  res- 
piration after  apparently  long  intervals  of  suspended  anima- 
tion has  saved  life. 

In  experimenting  on  dogs  the  author  has  found  that  reani- 
mation  of  the  heart  does  not  always  follow  artificial  respira- 
tion and  the  intraarterial  injection  of  normal  saline  solution 
and  adrenalin,  or  transfusion  of  blood.  In  some  of  the  cases 
in  which  these  procedures  are  begun,  even  within  a  couple  of 
minutes  of  cessation  of  the  heart  beat,  the  heart  cannot  be 
made  to  beat  again.  The  question  at  once  arises  as  to  why  this 
should  be.  Probably  the  most  frequent  cause  of  failure  Hes 
in  technical  obstacles,  such  as  blood-clot,  direct  injury,  and, 
above  all,  because  the  coronary  pressure  was  not  sufficiently 
raised.  Fibrillary  tremulation  is  perhaps  the  next  most  fre- 
quent cause.  Moreover,  if  infusion  be  given  too  rapidly  intra- 
venously the  right  heart  may  be  paralyzed  in  diastole.  The 
technique,  rather  than  the  latent  powers  of  reaction  of  the 
animal,  is  therefore  accountable  sometimes. 

'  As  to  the  practical  application  of  different  methods  by 
which  the  heart  may  be  made  to  beat  again,  it  is  found  that 
they  may  be  divided  into  two  groups — -the  indirect,  in  which 
the  heart  itself  is  not  made  accessible,  through  an  open- 
ing in  the  chest  wall  or  abdomen,  and  the  direct,  in  which  it  is 
made  accessible  or  is  directly  interfered  with,  as  in  tapping. 
Under  indirect  methods  will  be  considered  in  this  or  the  next 
chapter  (i)  compression  of  the  chest" wall;  (2)  electrical  ap- 
plications through  the  chest  wall  and  massage  of  the  heart 


2SO  SURGICAL  ANEMIA  AND  RESUSCITATION 

itself;  and  (3)  the  use  of  infusions,  i  In  discussing  all  of  these 
methods  it  is  to  be  understood  that  the  heart  has  actually- 
stopped  beating  before  beginning  treatment,  and  that  artificial 
respiration  is  being  carried  on  simultaneously  with  the  treat- 
ment. Before  taking  up  each  method  in  detail  delirium  cordis 
will  be  considered  briefly. 

Delirium  Cordis. — Aside  from  the  sensitiveness  of  the  cen- 
tral nervous  system  to  anemia  the  most  serious  obstacle  in  the 
way  of  resuscitation  is  delirium  cordis,  or  fibrillary  tremu- 
lation.  Up  to  the  present  time  no  satisfactory  method  of 
overcoming  it  has  been  found.  When  such  a  method  is 
discovered,  one  that  can  be  readily  applied  clinically,  a  great 
advance  will  have  been  made  toward  solving  the  problem  of 
cardiac  and,  hence,  general  resuscitation. 

In  performing  experiments  on  the  heart  all  physiologists 
have  noticed  the  phenomenon  of  delirium  cordis.  Frequent 
allusions  have  already  been  made  in  these  pages  to  vari- 
ous causes  of  this  condition.  Any  sufficiently  severe  stimulus 
and  many  stimuli  which  would  not  ordinarily  be  called  severe 
may  cause  it  to  appear.  The  stimulus  may  be  either  physical 
or  chemical  in  nature,  and  is  usually  most  efficacious  when  ap- 
plied directly  to  the  heart.  A  heart  which  has  ceased  beating 
and  has  then  been  made  to  beat  again,  whether  in  situ  or  iso- 
lated, may  show  delirium  instead  of  the  normal  rhythmic  con- 
tractions. Faradic  currents  of  even  weak  intensity  may  cause 
it.  Direct  currents  of  low  voltage,  up  to  120  volts,  are  par- 
ticularly likely  to  cause  it. 

Various  ways  of  overcoming  delirium  cordis  have  been 
used,  and  a  few  with  some  success,  at  least  in  the  laboratory. 
D'Halluin  considered  intravenous  injections  of  chlorid  of  po- 
tassium to  be  the  most  efficacious  treatment.  He  says :  "The 
heart,  after  having  been  poisoned  by  a  massive  dose  of  this 
drug,  may  beat  again  rhythmically  under  the  influence  of  the 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS       231 

massage  in  spite  of  the  previous  tremulations."  Then  he  goes 
on  to  say  that  this  poison  when  diluted  in  the  entire  blood  mass 
does  not  seem  to  have  any  more  action  on  the  heart  than  on  the 
rest  of  the  organism.  Of  all  the  many  things  which  he  tried 
this  was  the  least  toxic  and  most  easy  to  use. 

Among  inefficacious  substances  used  for  this  purpose 
d'Halluin  mentions  copper  sulphate,  corrosive  sublimate,  zinc 
lactate,  aluminum  sulphate,  barium,  strontium,  strophanthin, 
digitalin,  chloral,  atropin,  nicotin,  magnesium  sulphate,  sa- 
ponin, fluorescin,  curare,  and  magnesium  citrate.  The  ox- 
alates, the  fluorids,  cocain,  and  stovain  were  hardly  utilizable 
by  reason  of  the  injury  which  they  did  to  the  organism  in 
dosage  large  enough  to  stop  the  tremulations.  Only  the  salts 
of  ammonia  could  compare  with  chlorid  of  potassium,  and 
then  action  was  feeble. 

Among  inefficacious  methods  d'Halluin  found  that  electric 
discharges,  faradization  of  the  pneumogastric  nerves,  local 
cooling,  and  bandaging  with  dressings  wet  with  a  solution  of 
cocain  were  equally  useless. 

D'Halluin's  experience,  larger  than  that  of  any  other  one 
investigator,  coincides  with  the  experiences  of  everyone  else, 
except  possibly  Prevost  and  Batelli,  who  state  that  a  very 
powerful  and  rapidly  alternating  current  of  electricity  will 
arrest  tremulation.  Prevost  and  Batelli's  method  might  be 
useful  in  industrial  plants  in  which  such  currents  could  be 
commanded  at  an  instant's  notice,  special  arrangement  being 
made  for  treating  accidents  due  to  electrical  shock.  Otherwise 
this  method  would  be  entirely  impracticable  on  account  of  the 
lack  of  proper  facilities. 

f  Kesuscitation  of  the  Heart  by  Rhythmic  Pressure  on  the 
Thorax.) -In  dogs  the  forcible  rhythmic  compression  of  the 
thorax  over  the  heart  by  compressing  the  heart  itself  and  the 
great  vascular  trunks,  raises  the  blood-pressure  to  a  certain 


232  SURGICAL  ANEMIA  AND  RESUSCITATION 

extent  and  thus  aids  its  action.  The  mere  stimulation  of  the 
first  few  compressions  has  a  tendency  to  make  the  heart  re- 
sume automatic  action,  and  a  feeble  circulation  may  be  main- 
tained by  the  continuation  of  the  rhythmic  pressure  upon  the 
chest.  If  the  capacity  of  the  medullary  centers  be  early  in- 
creased by  the  subsequent  diminution  in  their  relative  anemia, 
the  resumption  of  heart  activity  is  much  more  apt  to  be  per- 
manent. Success  will  be  in  inverse  ratio  to  the  feebleness  of 
the  heart  beat,  if  present,  and  to  the  duration  of  its  inactivity, 
if  absent. 

/  In  adults,  and  especially  in  children,  something  can  doubt- 
less be  accomplished  by  forcibly  activating  the  elastic  chest 
wall.  With  the  child  flat  on  its  back,  pressure  should  be 
applied  at  the  rate  of  about  30  to  40  times  a  minute.  This 
will  also  afford  efficient  expiration,  as  in  the  Schafer  method 
the  elasticity  of  the  thorax  will  take  the  place  of  inspiratory 
efforts.  Care  should  be  taken  not  to  use  too  much  force,  al- 
though the  action  should  be  firm  and  vigorous.  The  applica- 
tions should  continue  for  at  least  twenty  minutes,  or  for  as 
much  longer  if  a  stethoscope  is  not  at  hand  so  that  the  lack  of 
heart  action  can  be  determined  with  accuracy.  If  no  action 
can  be  detected  with  the  stethoscope  at  the  end  of  twenty 
minutes,  there  is  little  or  no  hope  that  it  will  be  established, 
and,  in  all  probability,  the  higher  cerebral  centers  will  long 
have  been  past  hope  of  recovery,  1 

Resuscitation  of  the  Heart  by  Electrical  Stimulation  through 
the  Chest  "Wall. — In  the  opinion  of  the  author  the  advisability 
of  using  electric  currents  for  the  purpose  of  inaugurating  the 
heart  beat  is  doubtful.  With  a  current  of  fixed  character 
and  strength  uniform  results  doubtless  might  be  obtained, 
but  the  technical  side  presents  what  may  Ije  insurmount- 
able difficulties,  and  positive  and  irreparable  harm  may  be 
done.     The  great  danger  is  that  of  causing  fibrillary  con- 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS       233 

tractions  of  the  heart  muscle,  with  the  result  that  the  heart 
as  a  whole  becomes  an  inefficient  trembling  mass  of  tissue. 

In  cases  of  electric  shock  the  effect  on  the  heart  may  be 
summarized  as  follows :  ^ 

1.  Low  tension  currents  (up  to  120  volts)  cause  fibrillary 
contractions  and  hence  are  the  most  dangerous. 

2.  Currents  of  medium  tension  are  apt  to  have  the  same 
effect  but  are  more  likely  to  cause  general  inhibition. 

3.  High  tension  currents  cause  general  inhibition  through 
the  central  nervous  system. 

These  effects  vary  with  the  point  and  magnitude  of  the 
contact,  the  length  of  exposure,  and  the  direction  of  the  flow 
of  the  current. 

In  his  excellent  monograph,  "Resurrection  du  Cceur," 
d'Halluin  says  (page  172)  :  "The  fibrillary  tremors  of  the 
heart  are  the  principal  obstacle  which  is  opposed  to  the  re- 
sumption of  the  rhythmic  function  of  the  myocardium.  There- 
fore, one  will  carefully  azmd  every  measure  which  is  capable 
of  provoking  them,  and  one  zuill  not  run  a  risk  by  attempting 
the  direct  electrical  stimulation  of  the  heart  .  .  ."  What 
applies  to  the  direct  stimulation  of  the  heart  applies  with  equal 
force  to  stimulation  through  the  chest  wall. 

'""Direct  Methods  of  Resuscitating  the  Heart. — Three  so-called 
direct  methods  of  massaging  the  heart  have  been  employed, 
i.  e.,  methods  in  which  the  heart  is  manipulated  after  opening 
the  thorax  or  the  abdomen.  These  are  :  ( i )  The  intrathoracic, 
in  which  the  thorax  is  opened  and  the  heart  massaged  through 
the  opened  pericardium;  (2)  the  transdiaphragmatic;  and  (3) 
the  subdiaphragmatic.  In  the  second  method  the  heart  is 
massaged  from  the  abdomen  through  an  opening  near  the  ensi- 
form  cartilage,  the  diaphragm  being  cut  through  as  well  as 

*  From  a  research  made  in  collaboration  with  Dr.  J.  J.  Macleod.     See 

reference  No.  (&  in  Bibliography. 


234  SURGICAL  ANEMIA  AND  RESUSCITATION 

the  pericardium.  In  the  third  method  the  heart  is  massaged  by 
way  of  an  abdominal  incision  without  opening  the  diaphra^nj 

Intrathoracic  Method. — In  a  total  of  50  cases  of  clini- 
cal massage  of  the  heart  White  found  2  successful,  8  partially 
successful,  and  18  unsuccessful  cases  in  which  this  method  was 
used.  The  advantages  of  this  method  are  that  the  heart  is 
directly  under  the  hand  of  the  operator,  and  he  can  actually 
see  what  he  is  doing.  In  cases  in  which  wounds  of  the  heart 
have  to  be  dealt  with  there  is  no  doubt  but  that  this  should 
be  the  method  of  choice.  The  thorax  has  to  be  opened- any- 
way and  opening  the  abdomen  would  only  increase  the  surgi- 
cal risk.  The  great  disadvantages  of  this  method  are  the 
time  it  takes  to  make  the  exposure,  the  danger  of  opening  the 
pleura,  the  increased  danger  of  causing  shock,  and  the  general 
disadvantage  that  it  is  unnecessary  for  many  cases. 

The  Transdiaphragmatic  Method. — In  the  50  cases 
referred  to  above  White  found  only  3  (those  of  Mauclaire, 
Mauclaire  and  Coqueret,  and  Green)  in  which  transdia- 
phragmatic massage  of  the  heart  was  employed.  One  of  these 
was  partly  successful,  while  the  other  two  were  failures.  To 
the  mind  of  the  author  this  method  has  little  to  commend  itself 
— if  the  abdomen  is  to  be  opened  it  is  unnecessary,  except 
possibly  in  very  exceptional  cases  in  which  adhesions  might 
interfere  with  getting  a  good  grasp  of  the  heart. 

The  Subdiaphragmatic  Method. — This  is  by  all  means 
the  method  of  choice,  with,  as  already  stated,  the  exception  of 
cases  in  which  the  heart  or  thoracic  contents  have  to  be  ex- 
posed on  account  of  traumatism.  That  the  heart  can  be  read- 
ily reached  through  the  diaphragm  may  easily  be  demonstrated 
and  is  well  shown  in  the  frozen  longitudinal  section  made  by 
White  (see  Figs.  XIII,  XIV  and  XV).  White  gives  in  his 
table  8  successful,  5  partially  successful,  and  6  unsuccessful 
cases  of  the  application  of  this  method.     The  superiority  of 


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SURGICAL  ANEMIA  AND  RESUSCITATION 


this  method  is  indicated  by  the  fact  that  in  only  19  cases,  as 
against  28  in  which  the  direct  method  was  used,  there  were  8 


Fig.  XIV. — The  Thoracic  Viscera  as  Seen  from  the  Front,  the  Ribs 
AND  THE  Sternum  Intact. 
(Courtesy  of  Dr.  Charles   S.  White,  and  "Surgery,  Gynecology,  and 
Obstetrics.") 


recoveries,  or  four  times  as  many  as  in  the  larger  group  of 
cases — 42.1  per  cent,  as  against  7.1  per  cent.  As  the  majority 
of  major  operations  are  on  the  abdominal  viscera,  the  incision 
already  made  can  be  used,  or  enlarged  if  necessary. 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS        237 

In  considering  the  subject  of  cardiac  massage  as  a  whole 
it  is  impossible  to  refrain  from  calling  attention  to  the  fact 


Fig.  XV.— Same  as  Fig.  XIV,  the  Viscera  Being  Exposed  by  Removal 
OF  THE  Ribs  and  Sternum. 
(Courtesy  of  Dr.   Charles   S.  White,  and  "Surgery,  Gynecology,  and 
Obstetrics.") 

that  in  35  out  of  50  operative  cases,  or  in  70  per  cent.,  chloro- 
form was  the  anesthetic  used,  and  caused,  at  least  in  part,  the 
cardiac  collapse.  In  another  case  chloroform  and  ether  were 
given,  and  in  still  another  the  "A.  C.  E."  mixture  was  used. 


238  SURGICAL  ANEMIA  AND  RESUSCITATION 

This  fact  alone  should  point  the  way  to  the  prevention  of 
many  accidents  which  necessitate  the  use  of  cardiac  massage. 
Some  day  the  real  and  constantly  present  dangers  of  chloro- 
form will  be  universally  recognized.  As  long  as  this  anesthetic 
is  used  there  will  be  cases  of  collapse  in  which  desperate 
measures  will  have  to  be  taken  to  save  life. 

Experiments  show  that  when  the  heart  and  the  respiration 
have  stopped  the  brain  is  paralyzed  and  can  do  nothing.  And 
also,  that  when  the  heart  has  stopped  it  cannot  be  started  by 
any  nerve  stimulus. 

It  is  now  known  that  the  way  to  start  the  heart  is  to 
raise  the  pressure  in  the  coronary  arteries  and  to  supply  oxy- 
gen to  the  lungs  and  hence  to  the  blood,  but  that  the  way  to 
keep  it  heating  is  to  supply  oxygen  to  the  brain.  This  is  the 
key  to  the  entire  problem.  When  the  heart  acts,  then,  and 
only  then,  can  the  circulation  be  reestablished.  Confronted 
with  a  collapsed  patient,  in  whom  suspended  animation  implies 
a  quiescent  heart,  how  can  the  blood  pressure  in  the  coronary 
arteries  be  quickly  raised  to  40  mm.  or  more,  and  oxygen  be 
supplied  ? 

One  might  answer  that  cardiac  massage  should  be  suffi- 
cient to  reestablish  circulation,  but  experience  has  shown  that 
this  method  gives  inefficient  coronary  pressure,  because,  ist, 
but  little  blood  reaches  the  heart  and  hence  but  little  is  thrown 
out,  and,  2d,  the  vascular  system  is  collapsed,  so  that  the  small 
amount  of  blood  which  is  expelled  by  the  pressure  of  the  hand 
finds  collapsed  blood  vessels,  and  therefore  the  aortic  pressure 
is  not  raised  materially. 

It  might  then  be  supposed  that  saline  infusion  forced 
into  an  artery  toward  the  heart  would  so  raise  the  coronary 
pressure  as  to  activate  the  heart,  but  experiments  have  shown 
that  this  cannot  be  done  effectively.  The  saline  solution  is 
taken  up  in  large  quantity  by  the  relaxed  blood  vessels,  but  it 


RESUSCITATION  OF  THE  CIRCULATORY  APPARATUS       239 

escapes  from  the  blood  vessels  as  rapidly  as  it  enters,  and  col- 
lects largely  in  the  abdominal  viscera;  saline  solutions  there^ 
fore  cannot  produce  the  needed  rise  of  pressure  in  the  cor- 
onary vessels. 

Could  not  an  extreme  head-down  position  of  the  patient 
combined  with  bandaging  the  extremities  and  the  abdomen 
throw  such  a  volume  of  blood  into  the  thorax  and  into  the 
heart  that,  by  the  further  assistance  of  either  direct  rhythmic 
compression  of  the  heart  or  by  rhythmic  compression  of  the 
thorax  as  a  whole,  the  required  coronary  pressure  would  be 
supplied?  Here  again  experiments  have  given  a  negative  an- 
swer.   The  relaxed  vascular  trunks  again  cause  defeat. 

Failure  of  this  last  measure  means  that  the  peripheral  re- 
sistance must  be  so  raised  that  the  stream  of  blood  which  is 
thrown  out  of  the  heart  by  rhythmical  compression  may  react 
against  it  and  so  raise  the  aortic  and  hence  the  coronary  pres- 
sure. Can  this  increased  resistance  be  supplied  by  electric 
stimulation  of  the  vasomotor  mechanism?  All  such  efforts 
in  the  author's  hands  ha\e  failed.  It  is  obvious  that  the  cor- 
onary pressure  can  be  raised  to  40  mm.  or  more  only  by  the 
aid  of  a  drug  that  will  produce  a  vigorous  contraction  of  the 
arteries  against  which  the  blood  thrown  out  by  rhythmic  com- 
pression of  the  heart  may  react. 

Fortunately  in  adrenalin  there  is  such  a  drug,  but  adrenalin 
must  be  brought  into  direct  contact  with  the  walls  of  the  blood 
vessels.  This  can  be  done  by  infusing  it  into  the  circulation 
with  saline  solution.  Arterial  injection  should  be  employed 
rather  than  venous,  because  the  blood-pressure  is  dependent 
on  the  resistance  offered  by  the  muscles  of  the  arteries.  If 
injected  into  a  vein  the  adrenalin  must  pass  through  the 
right  auricle,  right  ventricle,  pulmonary  circulation,  and 
thence  to  the  left  auricle  and  left  ventricle  before  it  comes  in 
contact  with  the  walls  of  the  arteries  when,  for  the  first  time, 


240  SURGICAL  ANEMIA  AND  RESUSCITATION 

it  can  be  of  assistance  in  raising  the  aortic  and  hence  the  cor- 
onary pressure.  Not  only  is  this  a  circuitous  route,  entailing 
loss  of  time,  but  the  adrenalin  itself  must  be  somewhat  dissi- 
pated. It  wholly  lacks  the  directness  of  effect  secured  by  in- 
jecting it  toward  the  heart  through  an  artery.  Saline-adren- 
alin arterial  infusion  toward  the  heart,  combined  with  rhyth- 
mic pressure  upon  the  thorax  has  proved  most  efficient  in 
animals. 


CHAPTER    XI 

RESUSCITATION    OF   THE   BODY   AS   A   WHOLE — CONTINUED 

The  means  employed  for  resuscitation  in  suspended  anima- 
tion from  drowning,  from  anesthetic  accidents,  from  collapse 
in  operations,  from  injury,  or  whatever  the  cause  may  be  are 
roughly  divided  into  three  classes:  ist,  the  artificial  respiration 
and  stimulant  method;  2nd,  direct  massage  of  the  heart  added 
to  artificial  respiration  and  stimulation;  3rd,  the  adrenalin- 
saline  infusion  —  rhythmic  thoracic-pressure  method  devised 
by  the  author.  It  is  quite  obvious  that  all  of  the  methods  have 
their  indications  and  their  limitations. 

In  the  first  method,  the  use  of  artificial  respiration  has  the 
great  advantage  of  requiring  no  special  apparatus  and  being 
of  ready  application.  The  best  method  for  producing  artifi- 
cial respiration  has  already  been  considered.  Artificial  respira- 
tion alone  cannot  inaugurate  the  heart  beat,  but  when  there 
is  still  a  feeble  circulation  or  when  there  is  no  circulation  if 
there  is  a  rhythmic  contraction  of  even  the  auricles  this  method 
may  succeed.  Simple  artificial  respiration  is  the  only  hope  in 
drowning  and  other  accidents  occurring  when  professional 
help  is  not  at  hand.  Experiments  upon  animals  have  abun- 
dantly shown  that  as  far  as  asphyxia  is  concerned  a  very 
little  air  sustains  the  spark  of  life  for  a  surprisingly  long 
time. 

The  advantages  and  the  shortcomings  of  the  second 
method,  viz.,  that  of  direct  or  indirect  massage  of  the  heart 

241 


242  SURGICAL  ANEMIA  AND  RESUSCITATION 

added  to  artificial  respiration,  are  as  follows :  In  the  first 
place,  it  is  wholly  inapplicable  in  the  hands  of  the  layman. 
Even  in  professional  hands  the  large  wound  made  in  opening 
the  thorax  or  the  abdomen  and  inserting  the  hand  is  likely  to 
become  infected,  on  account  of  the  want  of  precaution  that 
haste  demands.  This  constitutes  in  itself  a  grave  danger. 
Then,  too,  aside  from  the  danger  of  such  a  wound,  the  effect 
of  direct  massage  on  the  heart  itself  is  most  serious.  It  may 
cause  fibrillary  contraction,  which  is  certain  to  defeat  resusci- 
tation, or  clotting  of  the  blood  in  the  chambers  of  the  heart 
may  result  from  the  physical  injury.  The  author  has  fre- 
quently seen  the  latter  occur.  There  is  one  point  of  advantage 
in  direct  massage  of  the  heart,  viz.,  in  the  course  of  abdom- 
inal operations  there  may  be  sudden  collapse.  If  this  happens, 
with  one  hand  in  the  abdomen  and  the  other  on  the  chest  the 
heart  may  be  rhythmically  compressed.  This  may  be  done 
with  little  loss  of  time,  while  preparations  are  being  made 
for  the  application  of  a  better  technique  to  be  described 
later. 

The  author's  experimental  researches  and  the  work  done 
by  others  may  now  be  summed  up  in  such  a  way  as  to  enable 
decision,  ist,  as  to  the  type  of  method  to  be  used  in  any  given 
case,  and,  2nd,  the  most  practical  technique  of  performing 
each  method.     This  summary  is  as  follows : 

The  various  organs  and  tissues  of  the  body  endure  anemia 
in  vastly  different  degrees.  The  part  that  endures  anemia 
least  well  is  the  brain.  The  cortex  is  killed  beyond  resuscita- 
tion in  about  seven  minutes.  In  order  to  save  the  brain 
reanimation  of  the  body  as  a  whole  must  begin  with  reanima- 
tion  of  the  heart. 

Even  while  the  heart  is  inactive  the  blood  may  be  artifi- 
cially circulated  through  the  brain  by  rhythmic  compression  of 
the  thorax  and  the  abdomen.     This  pressure  is  doubly  benefi- 


RESUSCITATION  OF  THE  BODY  AS  A  WHOLE  243 

cent ;  it  simultaneously  produces  artificial  respiration  and  arti- 
ficial circulation.  It  serves  to  supply  to  the  brain  enough  oxy- 
gen to  keep  the  slender  thread  of  life  from  breaking. 
In  artificial  respiration,  by  the  Schafer  method  especially,  an 
artificial  circulation  of  no  mean  value  is  simultaneously  pro- 
duced. 

/  It  must  be  borne  in  mind  that  when  any  part  of  the  body, 
but  especially  the  chest  and  the  abdomen,  is  subjected  to  pres- 
sure, the  valves  of  the  heart  and  of  the  veins  inevitably  cause 
the  blood  of  the  veins  to  flow  toward  the  heart  and  the  blood  in 
the  arteries  to  flow  toward  the  periphery.  Now  this  is  pre- 
cisely what  the  heart  does.  If,  instead  of  a  single  local  pres- 
sure, a  series  of  rhythmic  pressures  upon  the  thorax  and  abdo- 
men are  made  the  entire  blood  stream  may  be  energized  and 
moved,  that  is  to  say,  the  person  who  makes  the  rhythmic 
pressure  furnishes  an  external  pseudocardiac  action.  The  au- 
thor has  personally  been  able  to  effect  a  complete  circulation 
in  a  recently  dead  subject,  producing  a  radial  pulse  and  bleed- 
ing of  peripheral  vessels,  and  even  to  make  a  blood-pressure 
of  measurable  tension  (registered  by  a  sphygmomanometer) 
by  the  combined  effect  of  a  tightly  inflated  rubber  suit  cover- 
ing the  lower  extremities  and  the  abdomen  and  strong  rhyth- 
mic pressure  from  the  broadly  extended  hands  applied  upon 
each  side  of  the  chest.  Indeed,  the  face  could  be  made  to  flush 
and  fade  appreciably  at  will.  Undoubtedly  such  an  excellent 
method  as  Schafer's  for  producing  artificial  respiration  owes 
its  effectiveness  as  much  to  the  factor  of  artificial  circulation 
as  to  artificial  respiration.  This  point  seems  to  have  been 
missed. 

Schafer's  method  should  be  used  in  all  cases  in  the 
absence  of  medical  assistance  or  outside  of  a  hospital, 
and  even  in  a  hospital  in  the  absence  of  immediate  surgical 
aid. 


244  SURGICAL  ANEMIA  AND  RESUSCITATION 

THE  AUTHOR'S  METHOD   OF  RESUSCITATION 

The  author's  method  is  appHcable  only  in  a  hospital  service 
in  which  the  staff  is  trained  for  prompt  action,  and  the  simple 
apparatus  for  infusion  and  a  bottle  of  adrenalin  are  ever  in 
readiness.  A  staff  may  be  so  drilled  that  the  adrenalin  may 
be  introduced  in  two  minutes.     In  the  author's  method  the 


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Fig.  XVI. — Method  of  Giving  Adrenalin  by  Injecting  It  Directly  into 
A  Stream  of  Normal  Saline  Solution. 
The  needle  of  the  syringe  is  thrust  through  the  wall  of  the  rubber 
tube,  and  the  adrenalin  then  injected  with  rapidity  and  certainty  into  the 
circulation,  by  way  of  the  flowing  saline  infusion. 

patient  is  kept  in  a  supine  position.  Rhythmic  pressure  is 
made  on  the  thorax  and  upper  abdomen  for  the  double  purpose 
of  producing  artificial  respiration  and  artificial  circulation. 
Any  artery,  but  preferably  the  brachial,  is  laid  bare  with  rapid 
strokes  of  a  scalpel,  picked  up,  and  an  elliptical  hole  snipped 
into  it  with  scissors,  leakage  being  controlled  by  digital  pres- 
sure or  clamps.  Into  this  hole,  directed  toward  the  heart,  a 
small  cannula  of  an  ordinary  "funnel,  tube,  and  cannula  appa- 
ratus" filled  with  normal  saline  solution  is  inserted  and  tied. 
The  stream  is  allowed  to  flow  at  once  and  immediately  half 
the  contents  of  a  hypodermic  syringe  filled  with  adrenalin 
chlorid,  i-i,ooo,  is  injected  into  the  inflowing  saline  stream  as 


RESUSCITATION  OF  THE  BODY  AS  A  WHOLE  24$ 

near  the  artery  as  possible  by  piercing  the  rubber  tube,  or  is 
injected  directly  into  the  artery,  now  distended  with  salt  solu- 
tion (see  Fig.  XVI).  The  instant  this  is  done  the  rhythmic 
pressure  is  rather  vigorously  applied,  so  that  the  adrenalin  will 
be  distributed  as  widely  as  possible.  As  soon  as  the  coronary 
pressure  is  raised  high  enough  with  oxygenated  blood  the  heart 
will  begin  to  beat  with  a  strong  thump.  Care  must  be  taken 
not  to  cause  acute  dilatation  of  the  heart,  and  the  flow  should 
be  stopped  the  instant  blood  begins  to  be  forced  back  into  the 
tube  by  the  sudden  rise  in  blood-pressure.  If  resuscitation  is 
successful  the  artery  may  then  be  resected  and  an  end-to-end 
anastomosis  made.  J 

The  author's  associates,  Dr.  Lower,  Dr.  Dolley,  and  Dr. 
Sloan,  have  made  a  number  of  attempts  at  resuscitation,  some 
of  which  were  made  before  Dr.  Dolley  and  the  author  ascer- 
tained the  period  during  which  various  parts  of  the  brain  can 
endure  anemia.  These  experiences,  amounting  to  ten  in  all, 
may  be  briefly  summarized  as  follows :  The  cases  of  electro- 
cution resisted  every  attempt  at  reanimating  the  heart.  Later, 
in  the  before-mentioned  research  with  Prof.  MacLeod  on  the 
attempted  resuscitation  of  electrocuted  dogs,  it  was  found  that 
there  was  fibrillary  contraction  of  the  heart,  which  prevented 
resuscitation.  This  gives  an  almost  hopeless  aspect  to  cases  of 
suspended  animation  from  electric  shock. ^ 

In  other  cases  in  which  the  patients  were  drowned  and 
also  in  the  case  of  seriously  injured  persons  who  died  on  enter- 
ing the  hospital,  it  was  usually  possible  to  resuscitate  the  heart 
and  the  respiration  but  impossible  to  resuscitate  the  cerebrum. 

^  In  order  to  prevent  such  accidents  an  apparatus  was  devised  made  of 
wire  netting  which  fitted  snugly  around  each  Hmb  and  around  the  neck, 
the  upper  and  lower  parts  communicating  with  each  other  by  means  of 
insulated  wires.  In  this  manner  the  electric  currents  received  by  the  head, 
neck,  and  extremities  were  shunted  around  the  vulnerable  heart  and  the 
apparatus  served  as  a  sort  of  lightning  rod. 


246  SURGICAL  ANEMIA  AND  RESUSCITATION 

In  one  case  success  might  have  been  attained  had  there  not 
been  a  fatal  lesion  of  the  brain.  In  this  case  the  entire 
occipital  skull  was  crushed  deeply  into  the  brain.  Even  then 
the  resuscitation  succeeded  beyond  all  expectations.  The  heart 
quickly  began  beating  and  a  blood  pressure  of  80  mm.  was 
secured  and  sustained.  The  author  proceeded  to  elevate  the 
depressed  fractures,  the  patient  moving  about  during  the  cut- 
ting, but  as  the  fragments  were  raised  blood  gushed  out  from 
lacerated  sinuses.  The  wounds  were  packed  but  the  patient 
soon  died. 

In  another  case  a  patient  with  a  crushed  skull  who  died 
on  arrival  at  the  accident  room  was  reanimated  partially,  but 
the  reanimation  was  brief.  In  this  case,  also,  there  was  a 
mortal  wound  of  the  brain.  As  previously  stated,  the  fact,  that 
the  cortex,  the  associative  memory  part  of  the  brain,  was  so 
extremely  susceptible  to  anemia,  was  not  then  known. 

In  three  instances,  among  over  thirteen  thousand  personal 
operations,  the  author  has  seen  patients  succumb  on  the  operat- 
ing table  under  circumstances  which  permitted  an  attempt  at 
resuscitation.  In  the  very  first  case,  resuscitation  was  success- 
ful. The  patient  presented  a  serious  risk,  a  case  of  delirious 
Graves'  disease,  in  which,  in  the  course  of  operation  for  ex- 
cision of  the  lobe  of  the  thyroid,  collapse  occurred  without 
warning.  The  lobe  had  just  been  removed  and  the  wound  was 
ready  to  be  closed.  The  assistant  was  at  once  directed  to  make 
rhythmic  compression  on  the  chest  while  the  jugular  vein  was 
opened  and  adrenalin  and  saline  solution  introduced;  the  pa- 
tient meanwhile  seemed  to  be  dead.  The  heart  began  to  beat 
immediately  and  respiration  was  soon  resumed.  This  patient 
survived  the  immediate  effects  of  the  operation  and  resuscita- 
tion, but  died  later  with  symptoms  of  exhaustion  and  of  the 
disease. 

Another  case  was  that  of  sudden  collapse  while  an  at- 


RESUSCITATION  OF  THE  BODY  AS  A  WHOLE  247 

tempt  was  being  made  to  remove  a  tumor  of  the  brain  in  a 
child  of  eight.  The  tumor  was  situated  at  the  cerebellar-pon- 
tine  angle.  The  patient  was  in  a  very  emaciated,  weakened 
state,  and  a  poor  risk  for  any  operation.  In  the  course  of 
the  deep  dissection,  while  trying  to  dislodge  the  tumor,  the 
heart  and  the  respiration  suddenly  stopped,  and  the  child  was 
apparently  dead.  An  assistant  kept  up  rhythmic  pressure  on 
the  thorax  while  the  author  hastily  laid  bare  the  axillary  ar- 
tery, picked  it  up,  snipped  an  oblong  opening  in  it  and  inserted 
the  cannula  of  a  saline  apparatus  into  it.  The  solution  at  once 
flowed  into  the  axillary  artery  toward  the  heart,  and  15  minims 
of  adrenalin  chlorid  solution,  1-1,000,  were  injected  into  the 
rubber  tubing  near  the  cannula.  In  about  one  minute  the  heart 
began  to  beat  strongly,  and  the  saline  apparatus  was  at  once 
closed  by  a  clamp.  After  a  time  a  sudden  strong  spontaneous 
inspiration  occurred  and  eventually  respiration  was  resumed. 
The  wound  was  packed  with  iodoform  gauze,  a  dressing  was 
applied,  and  the  patient  sent  to  her  room.  In  several  hours 
absolute  death  followed  without  her  having  regained  con- 
sciousness. 

The  last  case  was  that  of  a  middle-aged  woman  who  had 
a  growing  tumor  of  the  uterus,  operation  upon  whom  had  been 
deferred  because  of  a  serious  lesion  of  the  heart.  At  times 
there  had  been  swelling  of  the  feet  and  nephritis.  Finally 
the  tumor  had  grown  so  large  and  caused  so  much  distress 
that,  despite  the  risk,  operation  was  undertaken.  The  patient 
went  through  the  operation  well  enough  until  the  wound  was 
nearly  sutured  and  the  anesthetic  had  been  removed,  when, 
without  warning,  the  heart  stopped.  Rhythmic  pressure  on 
the  chest  was  at  once  made,  the  axillary  artery  was  opened, 
and  adrenalin  in  saline  solution  was  given  as  before.  There 
was  some  delay  in  securing  a  response  from  the  heart,  but 
when  it  came  it  was  energetic.    The  respiration  did  not  appear 


248  SURGICAL  ANEMIA  AND  RESUSCITATION 

spontaneously  for  nearly  an  hour,  but  meanwhile  there  was 
good  circulation.  The  first  intimation  of  inspiration  was  a 
sudden,  long,  deep  breath.  Following  this  the  respirations 
were  slow,  deep,  and  of  a  sighing  type.  In  time  the  respiratory 
rate  increased  and  the  artificial  respiration  that  had  still  been 
maintained  as  a  precautionary  measure  was  discontinued. 
The  patient  was  taken  to  her  bed  and  Professor  G.  N. 
Stewart,  the  consulting  physiologist  to  Lakeside  Hospital,  was 
asked  to  see  her.  There  were  no  reflexes,  either  deep  or  super- 
ficial; no  response  to  painful  stimuli;  no  conjunctival,  nksal, 
laryngeal  or  pharyngeal  reflex ;  the  pupils  were  contracted  and 
did  not  respond;  and  the  intraocular  tension  was  markedly 
increased.  The  heart  beat  was  regular  and  ranged  from  90  to 
100  per  minute.  The  respiration  ranged  from  12  to  16  per 
minute.  These  two  functions  persisted  for  about  6  hours, 
when  both  gradually  failed. 

'  The  interpretation  of  the  failure  is  that  the  time  before 
inauguration  of  the  heart  beat  in  the  course  of  the  resuscita- 
tion was  unusually  long,  so  that  from  the  moment  of  collapse 
and  relative  death  to  the  moment  of  reestablishment  of  circula- 
tion was  about  9  minutes.  It  is  quite  certain  that  this  was  a 
clear  case  of  cerebral  death  before  death  of  the  respiratory  and 
circulatory  centers.  On  the  other  hand,  it  is  equally  certain 
that  had  the  heart  become  reanimated  as  quickly  as  in  former 
cases  the  patient  would  have  been  resuscitated  as  a  whole. 

From  the  other  experiments  on  the  resistance  of  other  tis- 
sues than  the  brain  which  have  been  reported  in  other  chapters 
of  this  volume  it  is  quite  certain  that  all  of  the  body  was  alive 
during  the  six  hours  following  the  resuscitation  excepting  that 
part  of  the  brain  in  which  associative  memory  and  other 
higher  functions  lie.  Assuming,  then,  that  the  cortex  died  on 
the  table  and  the  balance  of  the  brain  and  all  of  the  remainder 
of  the  body  lived  six  hours  longer,  when  did  the  patient  die? 


RESUSCITATION  OF  THE  BODY  AS  A  WHOLE  249 

/  The  author  and  his  associates  have  resuscitated  fully  one 
hundred  dogs  in  the  course  of  the  original  research  on  resus- 
citation and  in  the  numerous  demonstrations  of  the  technique 
to  those  interested.  In  comparing  the  results  with  the  resus- 
citation of  patients  he  is  convinced  that  the  human  heart  is  as 
readily  resuscitated  as  is  the  heart  of  the  dog.  I 


CHAPTER  XII 

GENERAL  RECAPITULATION 

LOCAL  ANEMIA 

Experimental  and  clinical  observations  of  total  anemia  of 
various  organs  and  tissues  of  the  body  have  been  presented 
in  the  foregoing  pages.  From  them  the  lesson  is  learned  that 
some  organs  or  tissues,  such  as  the  skin,  bone,  and  connective 
tissue  at  one  extreme  endure  anemia  for  many  hours,  while 
at  the  other  the  brain  endures  anemia  for  only  a  few  minutes. 
Moreover,  the  component  parts  of  organs  endure  anemia  un- 
equally; the  connective  tissue  framework  is  more  resistant  by 
far  than  the  parenchymal  cells,  and  there  is  strong  evidence 
that  the  power  to  endure  anemia  is  in  proportion  to  the  del- 
icacy of  the  function  of  an  organ  or  tissue. 

The  results  of  local  anemia  may  not  be  confined  to  the 
immediate  organ  affected,  but  may  produce  constitutional  dis- 
turbances. For  example,  anemia  of  a  muscle  may  result  in 
atrophy  and  functional  death  of  the  muscle  while  the  remain- 
der of  the  body  is  virtually  uninjured.  On  the  other  hand  the 
death  of  a  coil  of  intestine  not  only  destroys  the  coil  but  also 
results  in  the  formation  of  a  powerful  life-destroying  toxin 
which  acts  by  injuring  the  brain  cells  chemically.  Whether 
aseptic  necrosis  of  intestine  would  alone  furnish  this  toxin  is 
of  little  moment,  but  doubtless  tissue  necrosis  per  se  assists 
the  toxins  of  the  invading  bacteria.  Again,  aseptic  death  of 
a  kidney  or  spleen  might  cause  no  general  disturbance,  while 
septic  death  would  be  sure  to  do  so. 

250 


GENERAL  RECAPITULATION  251 

From  the  fact  that  there  is  a  pretty  sharply  defined  time 
limit  beyond  which  organs  cannot  survive  anemia,  many  im- 
portant lessons  are  to  be  learned.  A  common  example  is 
shown  in  the  application  of  bandages,  too  tight  applications 
resulting  either  in  death  of  a  limb  as  a  whole,  or  death  of 
only  certain  parts,  e.  g.,  of  the  muscle  fibers,  and  of  the  skin 
and  connective  tissue,  the  bone  alone  surviving. 

Another  important  underlying  principle  which  has  been 
strongly  proved  is  that  in  partly  or  wholly  anemic  organs 
the  susceptibility  to  infection  is  increased.  This  is  notably 
true  of  the  intestine  as  is  shown  by  the  ready  invasion  of  bac- 
teria into  the  intestinal  wall,  which  is  not  anemic  enough  to 
die  of  anemia  alone,  and  which  would  not  be  invaded  at 
all  if  it  were  not  anemic.  This  recalls  the  fact  that  previously 
injured  or  overworked  kidneys  are  more  susceptible  to  anemia 
than  are  normal  kidneys.  It  also  suggests  the  necessity  of 
avoiding  unnecessarily  long  pressure  of  clamps  on  the  intes- 
tines and  the  renal  pedicle,  not  only  so  as  not  to  cause  harm 
through  anemia,  but  also  to  avoid  lowering  the  resistance  to 
infection.  Finally,  these  studies  also  show  that  unconscious 
or  paralyzed  patients  should  be  protected  against  both  anemia 
and  infection  by  being  turned  in  bed  at  regular  intervals,  such 
individuals  having  lost  the  protecting  warning  of  beginning 
injury  which  pain  would  otherwise  give. 

RESUSCITATION 

Whatever  the  method  of  resuscitation,  the  one  primary 
and  essential  object  is  to  supply  the  brain  with  an  oxygenated 
circulation.  Artificial  respiration  can  be  maintained  indefi- 
nitely with  ease ;  the  heart  is  rather  readily  started,  but  unless 
cerebral  anemia  be  overcome  in  less  than  seven  minutes  the 
patient  passes  into  the  death  that  knows  no  awakening. 


BIBLIOGRAPHY 


Chapter  I 

1.  Crile  and  Dolley.    An  Experimental  Research  into  the  Resus- 

citation of  Dogs  Killed  by  Anesthetics  and  Asphyxia.  J.  Ex- 
per.  M.,  1906,  VIII,  713-715. 

2.  Hayem  et  Barrier.     Effets  de  I'Anemie  Totale  dc  I'Encephale 

et  de  ses  Diverses  Parties,  Studies  a  I'Aide  de  la  Decapitation 
suivie  des  Transfusions  de  Sang.  Arch,  de  physiol.  norm,  et 
path.,  Paris,  1887,  3  s.,  X,  1-45. 

3.  Hill,  Leonard.    Phil.  Tr.  Roy.  Soc,  1900,  CXCIII,  121. 

4.  Batelli,    F.      Restaurations    des    Fonctions    du    Coeur    apres 

I'Anemie  Complete.  Compt.  rend.  I'Acad.  de  sc,  Par.,  1900, 
CXXX,  800-803. 

5.  .  Influence  des  Differents  Composants  du  Sang  sur  la  Nu- 
trition des  Centres  Nerveux.  Jour,  de  physiol.  et  de  path, 
gen.,  1900,  II,  443. 

6.  Prus.      Ueber    die    Wiederbelebung    in    Todesfallen    in    Folge 

von    Erstickung,      Chloroformvergiftung,      und    electrischem 
Schlage.     Wien.  klin.  Wchnschr.,    1900,   XIII,  451-458;   482- 
487. 
7.  d'Halluin^   M.     Tremulations   Fibrillaires    dans   le   Massage   du 
Cceur.     Compt.  rend.  Soc.  de  biol..  Par.,  1904,  LVII,  1 18-120. 

8.  .  Le  Massage  du  Coeur.   Presse  med.,  Par.,  1904,  I,  345-349. 

9.  .    Diagnostic  Immediat  de  la  Mort.    i.  Critique  de  I'fipreuve 

de  la  Phlyctene  Explosible.  2.  Expose  d'un  Procede  Nouveau. 
Lille,  1906,  These. 

10.  Stewart,  Guthrie,  Burns,  and  Pike.    The  Resuscitation  of  the 

Central  Nervous  System  of  Mammals.  J.  Exper.  M.,  1906, 
VIII,  289-321. 

11.  Guthrie^  Pike^  and   Stewart.     The  Maintenance  of  Cerebral 

Activity  in  Mammals  by  Artificial  Circulation.  Am.  J. 
Physiol.,   1906-07,  XVII,  344-349. 

12.  Stewart  and  Pike.     Resuscitation  of  the  Respiratory  and  Other 

Bulbar  Nervous  Mechanisms  with  Special  Reference  to  the 
Question  of  Their  Automaticity,  Am.  J.  Physiol.,  1907,  XIX, 
328-359. 

253 


254  BIBLIOGRAPHY 

13.  Pike,   Guthrie,   and   Stewart.     Studies   in  Resuscitation. — 11. 

The  Reflex  Excitability  of  the  Brain  and  Spinal  Cord  after 
Cerebral  Anemia.     Ibid.,  1908,  XXI,  359-371. 

14.  Pike^    Guthrie^    and    Stewart.      Studies    in    Resuscitation. — I. 

The  General  Conditions  Affecting  Resuscitation  and  the  Re- 
suscitation of  the  Blood  and  of  the  Heart.  J.  Exper.  M., 
1908,  X,  371-418. 

15.  Stewart  and  Pike.     Loc.  cit.,  No.   12. 

16.  Hill,  Leonard.    The  Physiology  and  Pathology  of  the  Cerebral 

Circulation.     London,  1896,  132. 

17.  Mayer,  Med.  Centralbl.,  1878,  XVI,  579;  594. 

18.  Hayem,  G.     De  la  Mort  par  Hemorrhagic.     Arch,  de  physiol. 

norm,  et  path.,  Par.,  1888,  4s.,  I,  103-136. 

Chapter   II 

19.  Derby,  G.  S.     Ligation  of  the  Common  Carotid  Artery  for  Ma- 

lignant Recurrent  Hemorrhage  of  the  Vitreous.  J.  Am.  M. 
Ass.,  Chicago,  1907,  XLIX,  107-10. 

20.  Keller,  E.     Beitrag  zur  Kasuistik  des  Exophthalmus  pulsans. 

Zurich,  1898,  In.  Diss.,  207. 

21.  Siegrist,  a.   Die  Gefahren  der  Ligatur  der  grossen  Hals-schlag- 

adern  fiir  das  Auge  und  das  Leben  des  Menschen.  v. 
Graefe's  Arch.  f.  Ophth.,  1900,  L.  511-646. 

22.  Quenu.     a   Propos   de   la    Ligature   de   la   Carotide   Primitive. 

Bull,  et  mem.  Soc.  de  chir.  de  Par.,  1904,  n.  s.,  XXX,  686- 
694. 

23.  Verneuil.     Gaz.  des  hop.,  Par.,  1871,  442. 

24.  HoPMANN.     From   Siegrist,  loc.   cit.,   No.  21. 

25.  Wyeth,    J.    A.      Essays    in    Surgical    Anatomy    and    Surgery. 

New  York,  1879. 

26.  ScuDDER,  C.  L.     Cerebral  Embolism  following  Ligation  of  the 

External  Carotid  Artery.     Boston  M.  and  S.  J.,  1906,  CLIV, 

317. 

Chapter  IV 

27.  Keen,  W.  W.    A  Case  of  Ligature  of  the  Abdominal  Aorta,  etc. 

Am.  J.  M.  Sc,  Phila.,  1900,  CXX,  251-77. 

28.  Bristowe,  J.    S.     Three    Cases   of   Sudden    Obstruction   of   the 

Abdominal  Aorta  by  Aneurysm.  Lancet,  Lond.,  1881,  I,  131; 
166. 

29.  Pozzi,  M.   S.     Hernie  Mesenterique  Ancienne,  etc.     Bull,   et 

mem,  Soc.  anat.  de  Par.,  1872,  XLVII,  14-18. 


BIBLIOGRAPHY  255 

30.  Meynard.     L'Obliteration  de  I'Aorte  Abdominale  par  Embolic 

ou  par  Thrombose.     Paris,  1883,  These. 

31.  TuTSCHEK.     Ein  Fall  von  vollstandiger  Verstopfung  der  Aorta 

abdominalis  an  der  Theilungsstelle  in  Folgen  wahrer  Herz- 
thrombose  nach  abgelaufenem  Erysipelas  faciei.  Aerztl.  Int.- 
Bl.,  Miinchen,  1873,  XX,  257-263. 

32.  Barie   and   du   Castel.     £tude   Clinique   sur   les   Embolics    de 

I'Aorte  ct  Rccherches  Experimcntalcs  sur  la  Production  dcs 
Souffles  Cardiaques.  Arch.  gen.  de  med.,  Par.,  1881, 
CXLVII,  29-52. 

33.  Lauenstein,  C.     Ein  Fall  von  Embolic  der  Aorta.     Dcutschcs 

Arch.  f.  klin.  Med.,  Leipz.,  1876,  XVII,  491-496. 

34.  MoNTEiRO,  C.  B.     Observation  dc  Ligature  dc  I'Aorte  Abdomi- 

nale, Pratique  en   1842.     Rev.  med.-chir.  de  Par.,   1852,  XI, 

147-155- 

35.  TiLLAUX.     Anevrisme  Diffus  Consecutif  de  I'Artere  Iliaque  Ex- 

terne;  Ligature  de  I'Aorte.  Mort  au  Trentc-Ncuviemc  Jour. 
Bull,  et  mem.  Soc.  de  chir.  de  Par.,  1900,  XXVI,  473-475. 

36.  Gull,    W.      Paraplegia    from    Obstruction    of    the    Abdominal 

Aorta.     Guy's  Hosp.  Rep.,  Lond.,  1857,  III,  311-313. 

Chapter  V 

37.  Dreist,  K.    Ueber  Ligatur  und  Kompression  der  Arteria  iliaca 

communis.     Deutsche  Ztschr.  f.  Chir.,  Leipz.,  1903-4,  LXXI, 

5-34- 

38.  Gillette,  W.  J.     Ligation  of  the  Left  Common  Iliac  Artery. 

Ann.  Surg.,  1908,  XLVIII,  22-24. 

39.  MoscHOWiTZ,  A.  V.     Simultaneous  Ligation  of  Both  External 

Iliac  Arteries  for  Secondary  Hemorrhage  following  Bilateral 
Ureterolithotomy.     Ann.  Surg.,  1908,  XLVIII,  872-875. 

40.  Rabe,  L.     Zur  Unterbindung  der  grossen  Gefassstamme  in  der 

Continuitat  bei  Erkrankungen  und  Verletzungen  der  unteren 
Extremitaten.  Deutsche  Ztschr.  f.  Chir.  Leipz.,  1875,  V,  140- 
280. 

Chapter  VI 

41.  Barnard,  H.  L.  Two  Cases  of  Contracture  of  the  Flexors  of 
the  Forearm  Treated  by  Lengthening.  Lancet,  Lond.,  1901, 
I,  1 138. 
42.  Langer,  a.  Ein  Fall  von  ischamischer  Lahmung  durch  Embolic 
einer  Armatcrie  bewirkt.  Jahrb.  d.- Wien.  k.  k.  Krank.- 
Anstalt.,  1897,  IV,  375-82. 


256  BIBLIOGRAPHY 

43.  Barbier.     Deux  Cas  de  Contracture  Traumatique.     Bull.  Soc. 

clin.  de  Par.,  1884,  VIII,  151-158. 

44.  Freeman,  L.     The  Desirability  of  Early  Operations  upon  the 

Nerves  in  Ischemic  Paralysis.  Tr.  Am.  Surg.  Ass.,  Phila., 
1907,  XXV,  284-92. 

45.  Nevitt.     Gangrene  of  the  Hand  Induced  by  a  Tight   Sleeve, 

Recovery.     Canad.  Pract.,  Toronto,  1890,  XV,  97-99. 

Chapter  IX 

46.  Karsner   and  Austin.      Studies   in   Infarction.     Experimental 

Bland   Infarction.     J.   Am.   M.   Ass.,   Chicago,    191 1,   LVII, 

951-958. 

47.  LiTTEN.    Untersuchungen  iiber  die  hamorrhagischen  Infarct  und 

iiber  die  Einwirkung  arterieller  Anamie  auf  das  lebende 
Gewebe.    Ztschr.  f.  klin.  Med.,  Bed.,  1880,  I,  131-227. 

48.  Carrel^  A.    Transplantation  in  Mass  of  the  Kidneys.    J.  Exper. 

M.,  1908,  X,  98-140. 

49.  .    Remote  Results  of  the  Replantation  of  the  Kidney  and 

the  Spleen.    J.  Exper.  M.,  1910,  XII,  146-150. 

50.  EiSENDRATH   and  Strauss.     The  Effect  on  the  Kidney  of  the' 

Temporary  Compression  of  Its  Vessels.  J.  Am.  M.  Ass.,  Chi- 
cago, 1 9 10,  LV,  2286-2290. 

51.  Guthrie.     The   Effect  on  the   Kidney  of  Temporary  Anemia 

Alone  and  Accompanied  by  Perfusion.  Arch.  Int.  Med., 
Chicago,  1 910,  V,  232-45. 

52.  Carrel,  A.     Cultivation  of  Adult  Tissues  and  Organs  Outside 

of  the  Body.    J.  Am.  M.  Ass.,  Chicago,  1910,  LV,  1379-1381. 

53.  MacNider,  W.  de  B.     The  Pathological   Changes  Which  De- 

velop in  the  Kidney  as  a  Result  of  Occlusion  by  Ligation  of 
One  Branch  of  the  Renal  Artery.  J.  Med.  Research,  1910, 
XXII,  91-3. 

Chapter  X 

54.  IcARD.    La  Mort  Reelle  et  la  Mort  Apparente.    Nouveaux  Pro- 

cedes  de  Diagnostic  et  Traitement  de  la  Mort  Apparente. 
Paris,  1897. 

55.  D'Halluin,  M.    Contribution  a  I'fitude  des  Signes  de  la  Mort; 

Rubefaction  provoquee  au  Diagnostic  de  la  Persistance  de  la 
Circulation  dans  le  Cas  d'Absence  des  Bruits  du  Cceur.  Bull, 
med.,  Par.,  1906,  XX,  832. 

56.  ViERORDT.    Physiologic  des  Athmens,    Karlsruhe,  1845., 


BIBLIOGRAPHY  257 

57.  Keith.    Three  Hunterian  Lectures  on  the  Mechanism  underly- 

ing the  Various  Methods  of  Artificial  Respiration,  etc.    Lan- 
cet, Lond.,  1909,  I,  745 ;  825 ;  895. 

58.  ScHAFER^  E.  A.     Artificial  Respiration  in  Man.     Harvey  Lec- 

tures, Phila.,  1907-8,  223-243. 

59.  HiRSCH,  H.     Ueber  kiinstliche  Atmung  durch  Ventilation  der 

Trachea.     Giessen,  1905,  In.  Diss. 

60.  KuLiABKO.     Studien    ueber    die    Wiederbelebung    des    Herzens. 

Arch.  f.  d.  ges.  Physiol.,  Bonn,  1902,  XC,  461-474. 

61.  .  Neue  Versuche  ueber  die  Wiederbelebung  des  menschli- 

chen  Herzens.     Centralbl.  f.  Physiol.,  Leipz.  u.  Wien,  1902, 

XVI,  330. 

62.  .     Versuche  am  isolirten  Vogelherzen.     Ibid.,  588-90. 

63.  .    Weitere  Studien  ueber  die  Wiederbelebung  des  Herzens 

Arch.  f.  d.  ges.  Physiol.,  Bonn,  1903,  XCVII,  539-566. 

64.  D'Halluin,  M.    Resurrection  du  Coeur.    La  Vie  du  Coeur  Isole. 

Le  Massage  du  Cceur.     Paris,  1904. 

65.  .    Les  fitapes  de  la  Mort.    Compt.  rend.  Soc.  de  biol..  Par., 

1905,  LIX,  370. 

66.  .    Contribution  a  I'fitude  du  Massage  du  Coeur  (suite).    Les 

Tremulations  Fibrillaires.     Paris,  1905. 

6y.  Prevost  and  Batelli.  Quelques  Effets  des  Decharges  filec- 
triques  sur  le  Coeur  des  Mammiferes.  J.  de  physiol.  et  de 
path,  gen.,  Par.,  1900,  II,  40-52. 

68.  Crile  and  McLeod.  Some  Observations  on  the  Effect  of  Alter- 
nating Currents  of  Moderate  Frequency  on  Dogs.  Am.  J. 
M.  Sc,  Phila.,  1905,  CXXIX,  4^7-424- 


APPENDIX 

Through  the  courtesy  of  the  following  Commissions,  rep- 
resenting The  American  Medical  Association,  The  National 
Electric  Light  Association,  The  American  Institute  of  Electri- 
cal Engineers,  and  the  Bureau  of  Mines,  their  reports  and 
rules  are  reprinted  here  on  account  of  their  important  prac- 
tical bearing  upon  the  subject  of  this  monograph. 

REPORT  OF  THE   COMMISSION  ON  RESUSCITA- 
TION FROM   ELECTRIC   SHOCK 

The  electric  current  may  kill  either  by  temporarily  paralyz- 
ing the  nervous  control  of  the  muscles  of  respiration,  or  by 
stopping  the  regular  beat  of  the  heart.  When  the  heart  is 
seriously  affected  it  ceased  to  contract  as  a  whole,  but  continues 
to  contract  in  parts  here  and  there,  so  that  it  appears  to  quiver. 
It  is  then  said  to  ''fibrillate."  In  this  condition  the  heart  fails 
to  keep  the  blood  circulating,  and  death  quickly  results.  At 
present  no  practical  procedure  has  been  discovered  which  will 
restore  the  regular  beat  of  the  heart  in  man  after  it  begins 
fibrillating.  Hope  of  resuscitation  is  now  restricted  to  proper 
treatment  of  the  cases  of  paralyzed  respiration;  and,  since 
deprivation  of  oxygen  for  about  ten  minutes  injures  irreme- 
diably some  of  the  nerve  centers  of  the  brain,  it  is  particularly 
important  that  measures  for  resuscitation  be  applied  imme- 
diately and  continued  until  natural  breathing  returns.  In 
some  instances,  however,  the  heart  may  be  merely  weakened 
without  being  made  to  fibrillate ;  in  such  cases  artificial  respira- 
tion may  be  of  vital  importance,  because  a  greatly  weakened 

258 


APPENDIX  259 

heart  leads  to  impairment  or  total  stoppage  of  respiration, 
which  in  turn  destroys  the  last  vestige  of  the  heart-beat.  In 
all  cases,  therefore,  an  attempt  should  be  made  to  restore  natu- 
ral breathing.  Fortunately,  artificial  respiration  can  be  ap- 
plied by  laymen  without  immediate  need  of  complicated  appa- 
ratus. 

The  older  rules  for  artificial  respiration,  which  were  widely 
posted  in  this  country,  described  the  Silvester  method,  a 
method  which  directs  that  the  victim  of  the  accident  be  laid 
on  his  back,  and  his  chest  expanded  and  compressed  by  draw- 
ing his  arms  forward  and  then  pushing  them  back  against  his 
ribs.  After  these  rules  were  published,  however,  a  new 
method  of  artificial  respiration  was  devised  by  Sir  E.  A. 
Schafer,  of  Edinburgh,  called  by  him  the  "prone  pressure 
method."  It  consists  in  laying  the  victim  on  his  belly  and 
applying  pressure  rhythmically  on  the  loins  and  lowest 
ribs. 

Since  there  was  some  difference  of  opinion  regarding  the 
relative  merits  of  these  two  methods  of  artificial  respiration, 
and  since  the  time  seemed  ripe  for  a  revision  of  the  old  rules 
and  for  a  possible  standardization  of  new  rules  for  resuscita- 
tion. President  Gilchrist,  of  the  National  Electric  Light  Asso- 
ciation, requested  that  the  American  Medical  Association  and 
the  American  Institute  of  Electrical  Engineers  cooperate  with 
his  own  Association  in  this  undertaking.  Through  the  ap- 
pointment of  representatives  of  these  Associations  a  Commis- 
sion on  Resuscitation  from  Electric  Shock  was  organized  in 
the  autumn  of  1911,  with  the  following  membership: 

For  the  American  Medical  Association,  Dr.  W.  B.  Can- 
non (chairman),  Professor  of  Physiology,  Harvard  Univer- 
sity; Dr.  George  W.  Crile,  Professor  of  Surgery,  Western  Re- 
serve University ;  Dr.  Yandell  Henderson,  Professor  of  Physi- 
ology, Yale  University;  and  Dr.  S.  J.  Meltzer,  head  of  the  de- 


26o  APPENDIX 

partment  of  Physiology  and  Pharmacology  in  the  Rockefeller 
Institute  for  Medical  Research.  For  the  National  Electric 
Light  Association,  Dr.  E.  A.  Spitzka,  Director  and  Professor 
of  General  Anatomy,  Daniel  Baugh  Institute  of  Anatomy,  Jef- 
ferson Medical  College,  and  Mr.  Wm.  C.  L.  Eglin,  Past  Presi- 
dent of  the  National  Electric  Light  Association.  For  the 
American  Institute  of  Electrical  Engineers,  Dr.  A.  E.  Ken- 
nelly,  Professor  of  Electrical  Engineering,  Harvard  Univer- 
sity, and  Dr.  Elihu  Thomson,  Electrician,  General  Electric 
Company.  Mr.  W.  D.  Weaver,  editor  of  the  Electrical  Worlds 
was  elected  Secretary  of  the  Commission. 

The  Commission  was  confronted  with  three  problems : 
(i)  The  determination  of  the  best  manual  method  of  artificial 
respiration  that  can  be  instantly  applied  by  laymen,  and  the 
clear  description  of  that  method;  (2)  a  consideration  of  spe- 
cial mechanical  appliances  for  continuing  artificial  respiration, 
and  the  possible  invention  of  a  simple  and  effective  arrange- 
ment, the  action  of  which  might  be  quickly  and  easily  learned; 
(3)  an  investigation  of  the  possibilities  of  restoring  the  fibril- 
lating  heart  to  its  natural  pulsation.  The  third  of  these  prob- 
lems has  not  been  solved,  and  possibly,  because  of  the  sensi- 
tiveness of  important  nerve  cells  of  the  brain  to  lack  of  blood 
supply,  a  sensitiveness  which  results  in  abolition  of  their  func- 
tions when  deprived  of  blood  for  about  ten  minutes,  the  solu- 
tion of  the  problem  in  a  manner  permitting  the  life  of  the  indi- 
vidual to  continue  may  be  impracticable. 

The  Manual  Method  of  Artificial  Respiration 

The  advantages  claimed  for  the  Schafer  method  over  the 
Silvester  method  are  :  ( i )  Greater  simplicity  and  ease  of  per- 
formance; (2)  absence  of  trouble  from  the  tongue  falling  back 
and  blocking  the  air  passages;  (3)  little  danger  of  injuring 
the  liver  or  breaking  the  ribs  if  pressure  is  gradually  and  not 


APPENDIX  261 

violently  applied;  and  (4)  larger  ventilation  of  the  lungs. 
There  is  no  question  regarding  the  first  three  of  these  claims. 
The  claims  for  larger  ventilation  Professor  Schafer  supported 
by  experimenting  on  conscious  human  subjects.  He  compared 
the  volumes  of  air  taken  into  and  expelled  from  the  lungs  by 
the  prone  pressure  method  and  by  the  other  manual  pro- 
cedures of  artificial  respiration.  His  results  showed  a  to-and- 
fro  tide  of  air  sufficient  to  maintain  life  indefinitely  when  the 
prone  pressure  method  was  used,  but  a  volume  considerably 
less  than  normal  when  the  Silvester  and  other  methods  were 
employed. 

Professor  Schafer's  claim  for  larger  ventilation  with  his 
method  was  examined  by  Drs.  Henderson  and  Cannon  mainly 
on  conscious  healthy  men  and  by  Dr.  Meltzer  on  animals. 
When,  in  a  conscious  person  placed  in  the  prone  position,  arti- 
ficial respiration  is  substituted  for  normal  breathing,  the  re- 
sult indeed  is  a  taking  in  and  giving  forth  of  air  in  practically 
the  usual  amounts,  as  can  be  shown  by  a  gasometer.  Conse- 
quently when  the  operator  ceases  the  rhythmic  pressure  the 
subject  at  once  takes  up  his  natural  breathing  again.  He  does 
not  breathe  more  rapidly,  as  he  would  if  the  artificial  respira- 
tion had  been  insufTficient,  nor  does  he  cease  breathing  for  a 
moment,  as  he  probably  would  if  the  artificial  respiration  had 
been  excessive. 

Our  experiments  showed  that  the  pressure  applied  in  the 
Schafer  method  is  quite  sufficient  to  expel  the  air  from  the 
lungs  to  a  degree  not  surpassed  by  vigorous  efforts  at  expira- 
tion. Not  only  is  the  chest  diameter  lessened  from  front  to 
back,  but  further,  because  the  pressure  on  the  abdominal  vis- 
cera tends  to  force  the  diaphragm  upward,  the  chest  is  also 
lessened  in  extent  from  above  downward.  Schafer  declared 
that  the  natural  elasticity  of  the  chest  and  abdomen  causes  a 
resumption  of  their  original  positions  as  soon  as  pressure  is 


262  APPENDIX 

removed,  and  that  consequently  air  passes  into  the  lungs  as  in 
inspiration. 

The  fundamental  question,  however,  is  whether  the  taking 
in  of  air  because  of  the  elasticity  of  the  parts  will  be  the  same 
in  an  unconscious  as  in  a  conscious  person.  If  the  muscles  con- 
tinue to  exert  their  moderate  contraction  or  tone,  as  in  a  con- 
scious person,  the  parts  disturbed  by  pressure  will  evidently  be 
restored  to  their  former  positions  more  completely  than  if  the 
muscles  are  toneless.  Besides  this  tonic  contraction  of  the 
muscles  as  an  aid  to  inspiration,  it  is  highly  probable  that  quite 
involuntarily  the  conscious  subject  permits  the  normal  nerv- 
ous and  muscular  mechanism,  which  naturally  acts  without  in- 
volving volition,  to  expand  the  chest  and  thus  take  in  the  air. 
The  fact  that  natural  breathing  is  resumed  after  a  period  of 
artificial  ventilation  of  the  lungs,  without  any  indication  of 
too  little  respiration  or  too  much,  rouses  the  suspicion  that  the 
ventilation  is,  in  fact,  being  regulated  by  the  subject  involun- 
tarily. Consequently  a  testing  of  the  methods  of  artificial 
respiration  under  conditions  as  near  as  possible  to  those  in  the 
breathless,  toneless  subject  is  desirable. 

A  critical  examination  of  the  Schafer  and  other  methods 
of  artificial  respiration  was  undertaken,  early  in  1912,  by  Dr. 
Henderson  on  students  who,  after  over-ventilating  their  lungs 
by  two  or  three  minutes  of  voluntary  forced  respiration, 
showed  a  lack  of  desire  to  breathe  (apnea),  lasting  from  40 
to  80  seconds.  Schafer  had,  indeed,  produced  in  his  tests  some 
degree  of  apnea,  but  his  subjects  took  only  "several  deep 
respirations,"  and  the  apnea  seems  to  have  lasted  only  a  brief 
period  during  the  first  part  of  the  artificial  respiration.  In 
subjects  in  true  apnea  the  tone  of  the  muscles  would  be  re- 
tained, but  the  tendency  to  inspiration  after  the  breath  was 
pressed  from  the  chest  would  probably  be  reduced  to  a  mini- 
mum.    The   following  figures,  obtained  by  Dr.   Henderson, 


APPENDIX  263 

show  the  amount  (in  cubic  centimeters)  of  the  exchange  of 
air,  as  measured  by  a  gasometer  connected  with  the  subject's 
mouth,  in  men  in  true  apnea,  and  again  without  this  condi- 
tion, by  different  methods  of  artificial  respiration : 


Silvester 
method 

Schafer 

method 

(arms  flexed 

at  the  sides) 

Schafer 
method 
(arms  stretched 
forward) 

Natural 

breathing 

(at  the  same 

rate  as  the 

artificial) 

Subject  normal    . . . 

,       500-600 

500-600 

500-600 

500-600 

Subject  in  apnea 

.       150-200 

125-200 

200-300 

It  is  interesting  to  note  that  as  the  period  of  apnea  came 
to  an  end  the  movements  of  the  chest  were  increased  involun- 
tarily to  approximately  the  normal  extent.  In  some  cases  the 
artificial  movements  (on  non-apneic  subjects)  were  of  some- 
what greater  amplitude  than  the  natural ;  but  the  rate  was  cor- 
respondingly slower,  so  that  they  got  (or  rather,  quite  involun- 
tarily, they  took)  exactly  the  amount  of  air  that  they  needed — 
no  more  and  no  less.  According  to  the  results  obtained  with 
the  subjects  in  apnea,  the  Silvester  method  is  somewhat  more 
effective  than  the  Schafer,  when  the  subject's  arms  are  at  his 
sides.  The  latter  is,  however,  the  better  when  the  prone  pres- 
sure procedure  is  reinforced  by  the  inspiratory  position  of  the 
chest,  which  drawing  the  arms  forward  tends  to  induce.  In 
both  the  exchange  of  air  is  considerably  less  than  the  usual 
tidal  volume  (about  450  c.  c). 

These  results  have  recently  been  confirmed  by  Liljestrand, 
Wollin  and  Nilsson  (Skandinavisches  Archiv  fur  Physiologic, 
19 1 3,  xxix,  198),  who  found  that  the  amount  of  air  moved 
by  artificial  respiration  when  the  conscious  subject  was  in 
apnea  was  much  less  than  in  experiments  when  the  same  sub- 
ject was  not  in  apnea.  These  Swedish  observers  report  an 
insignificantly  greater  tide  of  air  (about  o.oi  liter)  with  the 
Silvester  method  than  with  the  Schafer  method.  They  paid 
no  attention  to  the  position  of  the  subject's  arms,  however, 


264  APPENDIX 

which  we  may  assume  not  to  have  been  drawn  forward.  In 
fact,  so  far  as  we  are  aware,  the  advantage  of  having  the  sub- 
ject's arms  extended  beside  his  head  so  as  to  pull  the  ribs  out- 
ward into  a  more  nearly  inspiratory  position  than  is  otherwise 
afforded  has  not  previously  been  referred  to  by  any  writer, 
although  it  has  been  reported  that  the  position  has  been  used 
by  English  coast  guards.  The  experiments  above  reported 
fully  demonstrate  its  importance. 

The  observations  of  Liljestrand,  Wollin,  and  Nilsson  (in 
part  upon  cadavers)  likewise  indicate  that  on  a  toneless  body 
the  exchange  of  air  induced  by  artificial  respiration  would 
probably  be  considerably  less  than  on  a  man  who  was  merely 
in  apnea.  The  following  observation  by  Dr.  Henderson 
points  to  the  same  conclusion,  but  suggests  that  the  tone  (or 
elasticity)  of  the  muscles  wears  off  gradually,  and  is  not  en- 
tirely lost  until  after  a  period  beyond  which  resuscitation  is  in 
any  case  impossible.  The  windpipe  of  a  cat  under  chloroform 
was  connected  with  a  small  gasometer  and  the  volume  of  the 
natural  breaths  recorded.  The  chloroform  was  then  adminis- 
tered in  such  amount  that  respiration  failed.  Artificial  respira- 
tion by  the  Silvester  method  was  given.  It  afforded  a  move- 
ment of  the  gasometer  at  first  only  about  a  quarter  as  large  as 
the  natural,  then  about  a  third,  then  about  a  half,  and  then 
spontaneous  breathing  returned.  Chloroform  was  again  ad- 
ministered until  both  breathing  and  heart  action  had  ceased. 
Artificial  respiration  now  gave  only  15  per  cent  of  the  normal 
volume.  Five  minutes  later,  i.  e.,  six  minutes  after  death,  it 
was  only  8  per  cent,  and  after  another  five  minutes  only  5  per 
cent. 

A  modification  of  the  Silvester  method  has  been  suggested  by 
Brosch,  in  that  the  arms  after  being  drawn  past  the  head  are  pressed 
downward  so  that  the  chest  is  raised  away  from  contact  with  the 
body's  support.     A  large  ventilation,  even  as  great  as  from  i  to  3 


,  APPENDIX  265 

liters  for  each  respiration,  has  been  reported  as  occurring  in  this 
procedure.  But  the  violent  and  painful  character  of  the  manipula- 
tion must  lead  to  as  great  participation  as  possible  by  the  subject  in 
order  to  minimize  the  degree  of  dislocation  of  the  parts,  and  the 
volumes  of  air  breathed  in  and  out  do  not  therefore  represent  solely 
the  mechanical  effects  of  the  procedure.  The  Brosch  modification 
of  the  Silvester  method  has  not  commended  itself  as  a  means  of 
artificial  respiration. 

Dr.  Meltzer  examined  the  efficacy  of  the  two  methods  on 
dogs  after  completely  abolishing,  by  means  of  curare,  all  possi- 
bility of  muscular  participation  by  the  animal  and  also  all  mus- 
cular tone.  Twelve  minutes  was  the  longest  time  during  which 
respiration  was  sufficient  to  keep  the  heart  beating  when  the 
Silvester  method  was  used,  while  with  the  Schafer  method 
the  shortest  time  was  eighteen  minutes  and  the  longest 
thirty-one. 

The  foregoing  observations  indicate  that,  so  far  as  the 
amount  of  ventilation  of  the  lungs  is  concerned,  the  Schafer 
method,  reinforced  by  the  extension  of  the  arms  forward,  is 
decidedly  better  than  that  suggested  by  Silvester.  And  this 
advantage,  taken  in  conjunction  with  its  greater  simplicity  and 
safety,  caused  the  Commission  to  vote  unanimously  in  favor  of 
the  prone  pressure  method  of  artificial  respiration  as  an  effec- 
tive means  of  giving  immediate  aid. 

After  a  careful  consideration  of  the  conditions  under 
which  accidents  occur,  and  of  the"  need  for  clear  and  brief 
statements  of  the  proper  procedures,  the  Commission  prepared 
a  description  of  facts  and  procedures,  which  has  been  issued  as 
a  booklet.  Since  the  manual  procedure  is  not  well  learned 
merely  by  reading  about  it,  superintendents,  foremen  and 
others  having  charge  of  men  are  advised  in  the  booklet  to  give 
practical  instructions  and  demonstrations  on  the  use  of  the 
rules  to  all  employees.  Besides  the  booklet  the  Commission 
has  prepared  a  slight  abbreviation  of  Sections  i,  2,  and  3  of 


266  APPENDIX 

the  Instructions,  which  has  been  issued  as  a  chart  to  be  posted 
in  central  stations  where  accidents  are  likely  to  occur. 

Mechanical  Devices  for  Artificial  Respiration 

The  Need  for  Mechanical  Devices 

In  experimental  attempts  to  cause  death  of  animals  by 
ether,  chloroform,  illuminating  gas,  drowning,  etc.,  respira- 
tion sometimes  returns  spontaneously  after  a  complete  suspen- 
sion for  two  minutes  and  longer.  For  this  reason  it  is  often 
difficult  to  decide  whether  the  restoration  of  respiration  has 
really  been  brought  about  by  any  manipulation  which  has  been 
applied.  Only  when  such  manipulation,  applied  to  a  living  ani- 
mal unable  to  breathe,  keeps  up  a  sufficient  exchange  of  res- 
piratory gases  to  maintain  the  circulation  for  a  considerable 
period,  and  when  discontinued  no  spontaneous  respiration  sets 
in,  is  the  conclusion  strictly  justified  that  the  manipulation  is 
efficient  for  artificial  respiration.  The  keeping  alive  of  com- 
pletely curarized  animals  by  artificial  respiration  is  therefore 
the  most  rigorous  proof  for  the  efficiency  of  any  method.  The 
methods  applied  to  human  beings  have  not  been  tested  in  this 
rigid  manner.  The  air  exchange  effected  by  the  various 
methods  has  been  determined  on  healthy  conscious  individuals, 
not  on  the  relaxed  victims  of  drowning  and  shock,  and  the  re- 
covery of  the  victims  by  one  method  or  another  is  cited  as  evi- 
dence of  the  value  of  the  method.  Keith  has  examined  the  an- 
nual reports  of  the  Royal  Humane  Society  for  the  past  140 
years,  and  in  hundreds  of  instances  recovery  of  the  apparently 
drowned  has  been  reported  when,  at  different  times,  the  chief 
means  employed  were  fumigation  (rectal),  or  warmth,  or  in- 
flation (mouth  to  mouth),  or  friction,  or  artificial  respiration 
by  manual  methods,  or  combinations  of  these  (see  Lancet, 
1909,  p.  897). 


APPENDIX  267 

Since  a  certain  percentage  of  cases  recover  spontaneously, 
each  one  of  these  methods  has  been  credited  with  causing  re- 
covery, and  yet  an  examination  shows  that  some  of  them,  as 
fumigation,  friction,  and  warmth,  have  no  direct  effect  on 
breathing.  Although  the  manual  methods  of  artificial  respira- 
tion provide  an  exchange  of  air,  the  amount  of  which  in  the 
toneless  victim  has  not  been  accurately  determined,  they  prob- 
ably afford  a  sufficient  exchange  of  air  until  dangers  from  tem- 
porary causes  are  averted.  Thus,  in  mild  cases  of  respiratory 
failure,  in  which  reflex  irritability  of  the  breathing  mechanism 
is  retained,  and  therefore  a  tendency  to  recovery  exists,  these 
methods  may  be  of  the  utmost  value  in  reestablishing  the  nor- 
mal movements.  Certainly,  in  all  cases  when  breathing  is  sus- 
pended and  no  better  means  are  at  hand  to  supply  air  to  the 
lungs,  manual  methods  should  be  used,  and  of  these  the  most 
commendable  is  the  prone  pressure  method  with  arms  ex- 
tended forward.  Even  a  relatively  poor  method  of  artificial 
respiration,  if  begun  immediately,  may  maintain  life  and  per- 
mit ultimate  recovery  in  cases  in  which  an  ideal  method  with 
all  the  resources  of  laboratory  and  hospital  would  be  ineffec- 
tive after  a  delay  of  a  few  minutes.  If,  owing  to  delay,  certain 
cells  of  the  brain  have  been  deprived  of  their  supply  of  oxygen 
for  more  than  the  critical  period  (rarely  more  than  ten  min- 
utes), it  is  utterly  impossible  for  any  later  treatment  to  restore 
them  to  their  normal  condition. 

Because  the  amount  of  ventilation  supplied  by  this  modified 
prone  pressure  method  in  apneic  subjects  may  be  close  to  a 
dangerous  minimum,  mechanical  devices  assuring  more  effi- 
cient respiration  than  can  be  assured  by  manual  methods  are 
desirable.  In  order  to  test  the  action  of  devices  now  being  ad- 
vocated, a  subcommittee,  with  Dr.  Meltzer  as  chairman,  was 
appointed.     The  apparatus  examined  was  used  according  to 


268  APPENDIX 

directions,  and  the  effects  were  demonstrated  before  the  mem- 
bers of  the  Committee. 

Commercial  Mechanical  Devices 

At  least  four  machines  for  performing  artificial  respiration 
are  now  in  the  market — the  Pulmotor,  the  Dr.  Brat  Apparatus, 
the  Lungmotor,  and  the  Salvator.  The  last  two  devices  have 
not  been  examined.  The  first  two  machines  are  alike  in  pro- 
viding for  inspiration  by  oxygen  pressure  and  for  expiration 
by  suction.  In  the  pulmotor  the  inspiratory  air  contains  only 
60  per  cent  oxygen,  while  in  the  Dr.  Brat  apparatus  it  is  all 
pure  oxygen.  In  the  latter  apparatias  the  respiratory  changes 
are  made  by  hand,  while  in  the  pulmotor  they  are  made  auto- 
matically by  the  mechanism  of  the  instrument.  The  apparatus 
of  Dr.  Brat  was  used  by  some  surgeons  in  experimental  intra- 
thoracic work  while  its  inventor  was  alive,  but  it  seems  never 
to  have  become  a  successful  commercial  article.  The  pul- 
motor, on  the  other  hand,  although  it  has  lacked  scientific,  sur- 
gical, and  medical  sponsors,  has  received  wide  publicity 
through  the  daily  press. 

The  Pulmotor 

The  pulmotor  is  manufactured  by  the  Draeger  Works  in 
Liibeck,  Germany,  manufacturers  of  various  rescue  apparatus. 
The  firm  has  a  very  active  agency  for  its  goods  in  Pittsburgh. 
Although  several  years  have  passed  since  the  pulmotor  was 
introduced  in  Germany,  the  medical  literature  of  that  country 
has  only  one  publication  on  this  machine,  a  short  article  by  Dr. 
Roth  (Berliner  klinische  Wochcnschrift,  Sept.  18,  191 1), 
known  for  the  Roth-Draeger  inhalation  apparatus.  In  this 
article  Dr.  Roth  states  that  he  had  made  experiments  on  ani- 
mals and  human  cadavers  with  the  machine  several  years  be- 
fore. He  found  that  air  is  liable  to  be  driven  into  the  stomach. 


APPENDIX  269 

but  that  this  can  be  prevented  by  pressure  on  the  trachea.  Al- 
though years  passed  by  after  the  introduction  of  this  appara- 
tus and  although  Germany  has  many  active  life-saving  socie- 
ties, no  medical  report  of  its  use  in  a  single  case  has  appeared 
in  the  very  prolific  medical  literature  of  that  country.  Jelineck 
{Wiener  medezinische  Wochenschrift,  1912,  No.  25)  men- 
tions the  efficiency  of  the  pulmotor,  but  his  knowledge  of  the 
machine  is  derived  from  the  brief  article  of  Dr.  Roth  and 
from  a  report  sent  to  him  by  the  Pittsburgh  agency,  that  Dr. 
Sherman,  in  Pittsburgh,  saved  two  lives  with  this  machine. 

In  the  medical  literature  of  this  country  the  following  no- 
tices have  been  found : 

The  Journal  of  the  American  Medical  Association  for  Au- 
gust 31,  191 2,  contains  an  answer  to  a  question  regarding  the 
pulmotor,  with  a  reference  to  Dr.  Roth's  article  and  to  the  re- 
ports in  Chicago  newspapers. 

McCombes,  of  Philadelphia,  in  an  article  on  illuminating 
gas  poisoning  in  the  American  Journal  of  Medical  Sciences, 
Oct.,  1912,  says  of  the  pulmotor:  "It  maintains  artificial  res- 
piration perfectly.  Reports  from  all  over  the  country  relative 
to  its  efficiency  have  been  received.  Whenever  possible  it 
should  be  used."  He  does  not  say  from  whom  and  by  whom 
the  reports  were  received.  From  a  study  of  the  wording  of 
this  writer  it  is  highly  probable  that  he  had  neither  personal 
experience  with  cases  nor  any  medical  literature  at  his  dis- 
posal. 

In  volume  VI  of  Keens  Surgery  is  an  article  by  W.  L. 
Estes  (Director,  Physician,  and  Surgeon-in-Chief  of  South 
Bethlehem,  Pa.),  in  which  there  is  a  picture  of  the  pulmotor 
used  in  the  act  of  resuscitation.  Quoting  the  Survey,  he  states 
that  the  Red  Cross  First  Aid  car  is  equipped  with  "the  pul- 
motor for  restoring  respiration  to  asphyxiated  persons."  Not 
a  single  report  of  personal  knowledge  has  been  found  in  a 


27©  APPENDIX 

standard  medical  journal.  And  only  when  an  observer  pub- 
lishes his  experience  in  detail,  gathered  in  a  number  of  cases, 
can  we  judge  whether  his  observations  are  unbiased,  his  state- 
ments truthful  and  his  conclusions  justifiable. 

By  the  kindness  of  the  head  physician  to  the  New  York 
Edison  Co.,  opportunity  was  obtained  to  examine  21  records 
of  gas  poisoning  in  which  the  pulmotor  was  reported  as  having 
been  used  with  success.  Most  of  the  reports  were  written  by 
chauffeurs  and  a  few  only  by  physicians.  In  most  of  the  re- 
ports no  distinction  was  made  between  unconsciousness  and 
absence  of  respiration.  In  a  few  cases  only  was  there  reason 
to  suppose  that  respiration  might  have  been  suspended.  Let- 
ters sent  to  the  various  physicians  mentioned  brought  either 
an  unsatisfactory  answer  or  none  at  all.  Of  two  additional 
cases  which  were  reported  no  machine  was  used  in  one,  and 
in  the  other,  a  case  of  opium  poisoning,  an  entirely  different 
method  (intratracheal  insufflation)  was  employed. 

A  series  of  reports  made  by  miners  to  the  Bureau  of 
Mines  and  another  series  made  by  several  physicians  were  ex- 
amined. The  miners'  reports  comprise  few  cases.  In  one 
case,  according  to  the  daily  press,  the  man  was  revived  by  the 
pulmotor,  while  the  report  does  not  even  mention  the  pulmotor, 
and  the  physician  in  attendance  expressed  the  belief  that  suc- 
cess was  due  to  hypodermic  treatment.  Of  the  remaining  nine 
cases  four  were  revived  by  the  administration  of  oxygen,  and 
two  by  the  Silvester  method  of  artificial  respiration  in  com- 
bination with  oxygen.  In  the  seventh  case  (Webb)  the  Silves- 
ter method  had  been  applied  for  three  minutes  and  was  fol- 
lowed immediately  by  the  pulmotor  for  six  minutes.  In  the 
eighth  case  (Burgess)  the  pulmotor  was  first  applied  thirty 
minutes  after  the  victim  had  been  removed  from  the  gas  at- 
mosphere. No  statement  was  made  as  to  what  was  done  for 
him  in  the  interim.    In  the  ninth  case  (Enzian)  Dr.  McGuire, 


APPENDIX  271 

of  Wilkes-Barre,  "endeavored  for  two  hours  to  revive  her  by 
artificial  respiration.  Failing  in  this,  a  pulmotor  was  brought 
a  distance  of  eight  miles,  and  under  the  manipulation  of  Mr. 
G.  T.  Holdaman  the  patient  was  revived  in  two  or  three 
hours."  Cases  eight  and  nine,  in  which  the  victims  lived  a 
long  time  before  the  application  of  the  pulmotor  (half  an  hour 
and  two  hours),  do  not  present  convincing  evidence.  In  case 
seven  the  pulmotor  did  at  least  as  much  as  the  Silvester 
method;  but  that  does  not  show  it  did  more,  since  the  same 
result  might  have  been  attained  if  the  pulmotor  had  been  used 
first  and  the  Silvester  method  later.  These  reports  are  in  no 
manner  satisfactory  documents  for  demonstrating  the  supe- 
riority of  the  pulmotor  as  a  device  for  artificial  respiration. 

The  second  series  consists  of  statements  of  physicians 
transmitted  by  Dr.  Wm.  O'Neil  Sherman,  chief  surgeon  of 
the  Carnegie  Steel  Co.  in  Pittsburgh.  It  comprises  reports  of 
seven  cases  in  which  the  pulmotor  was  used  successfully.  Dr. 
Sherman  himself  reports  two  cases.  In  the  first  (June  20, 
1912)  a  collapse  occurred  during  an  amputation,  "breathing 
ceased,  pupils  dilated  and  did  not  react  to  light,  with  a  very 
small,  thin  pulse."  "The  pulmotor  was  brought  into  use,  and 
as  a  result  the  patient  soon  began  breathing  normally  (italics 
ours  here  and  elsewhere),  recovering  from  the  collapse  in  ten 
minutes."  In  the  second  case  (Dec.  20,  1912)  nitrous-oxid- 
oxygen  anesthesia  was  being  given,  "when  respiration  sud- 
denly ceased,  eye  reflexes  absent,  pupils  fixed,  cyanosis  gradu- 
ally increasing,  pulse  weak  and  slow.  Artificial  respiration 
(Silvester  method) — tongue  drawn  out,  cyanosis  becoming 
greater.  Artificial  respiration  was  continued  with  no  sign  of 
returning  respiration  for  two  and  a  half  minutes.  Pulmotor 
was  then  used;  respiration  returned  in  one  to  one  and  a  half 
minutes;  cyanosis  soon  cleared  up,  and  the  operation  continued 
under  ether." 


272  APPENDIX 

Dr.  Urmson,  Newcastle,  Pa.,  reports  (Dec.  23,  1912)  the 
case  of  a  man  overcome  by  gas  .  .  .  "it  was  impossi- 
ble to  detect  any  sign  of  respiration.  Mask  was  applied  and 
pulmotor  started ;  in  a  short  time  patient  showed  marked  signs 
of  improvement."     This  patient  recovered. 

Dr.  Botkin,  Duquesne,  Pa.,  reports  (April  20,  19 12)  the 
case  of  a  strangulated  man,  his  clothes  having  been  caught  in 
the  drill  of  the  press.  Respiration  stertorous,  10  or  12  per 
minute.  "We  immediately  cleared  his  mouth  and  throat  of 
mucus  and  gave  oxygen  by  use  of  pulmotor."  "It  did  splen- 
did work,  inflating  his  lungs  fully  and  regularly,  and  estab- 
lished normal  respiration."  (Natural  respiration  had  not 
stopped  in  this  case.) 

Dr.  Evans,  Union  Mills,  Youngstown,  Ohio,  reports  (Dec. 
17,  1912)  the  case  of  a  man  overcome  by  gas,  "unconscious, 
scarcely  if  any  respiration,  pulse  weak.  Pulmotor  applied, 
kept  going  for  five  minutes,  respiration  returned,  pulse  became 
stronger  and  consciousness  returned." 

Dr.  Rossiter,  company  surgeon,  Swissdale,  Pa.,  reports 
two  cases  of  "gassing."  In  one  case  (Nov.  21,  1912)  "the 
patient  was  unconscious,  not  breathing,  no  pulse,  and  I  was  not 
\^sic'\  able  to  detect  only  faint  flutter  of  the  heart.  The 
pulmotor  was  used,  and  in  the  course  of  about  ten  minutes  the 
man  showed  signs  of  life,  and  after  keeping  it  on  for  about 
twenty  minutes  he  was  almost  completely  revived."  In  the 
second  case  of  "gassing"  (Dec.  28,  1912)  "the  patient  was  un- 
conscious, had  no  pulse,  no  signs  of  respiration,  very  feeble 
heart,  loss  of  all  reflexes.  Before  I  arrived  the  hospital  at- 
tendant performed  artificial  respiration  in  connection  with  the 
inhaling  device  of  the  pulmotor.  I  continued  this  treatment 
after  my  arrival  for  about  one-half  hour,  at  the  end  of  which 
time  there  was  very  little  change  in  the  patient.  I  then 
switched  over  the  pulmotor  and  adjusted  it  without  pulling 


APPENDIX  273 

out  the  tongue  or  pressing  on  the  larynx.  In  the  course  of 
a  few  minutes  the  patient  began  to  move  his  head,  and  in  ten 
to  fifteen  minutes  he  started  to  fight  and  wanted  to  sit  up." 
(In  this  case  manual  artificial  respiration  combined  with  oxy- 
gen was  capable  of  keeping  up  the  respiratory  function  for 
longer  than  half  an  hour.) 

In  five  of  these  cases  the  pulmotor  was  used  only  a  few 
minutes,  and  furtherrnore  respiration  was  restored  so  soon 
after  it  had  ceased  that  the  conclusion  that  the  pulmotor  was 
essential  is  not  justified.  The  evidence  is  similar  to  that  in 
the  cases  of  the  apparently  drowned,  previously  cited,  who 
were  restored  by  fumigation  or  friction.  In  another  case 
spontaneous  breathing  was  not  absent,  and  therefore  the  credit 
of  restoration  does  not  belong  to  the  instrument.  The  last 
two  cases  are  the  most  favorable  to  efficiency  of  the  pulmotor, 
and  in  one  of  these  the  support  of  life  by  manual  respira- 
tion for  more  than  half  an  hour  is  rather  in  favor  of  that 
method. 

Although  the  cases  reported  above  do  not  furnish  convin- 
cing proof  of  the  necessity  or  the  exceptional  value  of  the  pul- 
motor, that  instrument  is  probably  capable  of  creditable  per- 
formance, and  doubtless  has,  in  some  instances,  favored  the 
restoration  of  normal  breathing.  Its  present  vogue,  however, 
is  not  supported  by  a  critical  examination  of  the  principles  in- 
volved in  its  mechanism  or  of  its  effects  when  used  for  long 
periods.  As  stated  above,  no  well-considered  testimony  to  its 
action  is  to  be  found  in  medical  literature,  and  in  this  country 
at  least  its  loudest  sponsors  are  the  newspapers,  which  have 
spread  the  impression  that  the  pulmotor  is  a  perfect  and  most 
reliable  resource  when  respiration  is  suspended. 

A  high  official  of  one  of  the  important  electric  companies 
in  the  country  testified  to  a  member  of  the  Committee :  "We 
have  to  buy  these  machines,  even  if  they  are  no  good,  as  an 


274  APPENDIX 

evidence  of  our  good  faith  and  our  desire  to  do  everything 
possible  to  safeguard  the  public  and  employees." 

Experiments  with  Commercial  Devices  for  Artificial  Respira- 
tion 

The  effects  of  the  Dr.  Brat  apparatus  and  the  pulmotor 
were  studied  by  the  subcommittee  in  experiments  on  anes- 
thetized and  curarized  animals.  The  animals  were  thus  doubly 
prevented  from  making  any  response  to  the  action  of  the  ap- 
paratus, and  were,  therefore,  in  a  condition  analogous  to  ex- 
treme prostration.  The  Dr.  Brat  apparatus,  obtained  by  cour- 
tesy of  the  Westphalia  Engineering  Co.,  was  used  in  a  few  ex- 
periments only,  but  the  results  were  in  essential  points  similar 
to  those  secured  with  the  pulmotor.  One  pulmotor  used  was 
loaned  by  the  Pittsburgh  station  of  the  Government  Bureau 
of  Mines.  On  returning  the  machine,  Mr.  Paul,  the  mining 
engineer  in  charge  of  the  station,  stated  that  the  machine  was 
in  the  same  good  working  condition  when  returned  as  it  was 
when  sent.  Another  pulmotor,  loaned  by  the  New  Haven  Gas 
Co.,  was  also  tested,  and  gave  confirmatory  results.  Experi- 
ments were  performed  on  dogs,  cats,  and  rabbits.  The  oxy- 
gen was  applied  through  specially  constructed  masks  adapted 
to  the  individual  animals.  The  efficiency  of  these  masks  was 
tested  by  other  respiratory  apparatus  at  hand  in  the  laboratory. 
The  tongue  was  kept  well  pulled  out.  In  several  experiments 
the  trachea  was  connected  by  means  of  a  lateral  cannula  with 
a  water  manometer.  In  some  cases  also  the  intrapleural  pres- 
sure was  measured,  and  in  others  the  thorax  was  opened  and 
the  behavior  and  appearance  of  the  lungs  observed. 

Of  eleven  dogs  only  one  small  animal  (under  4  kilos),  com- 
pletely curarized,  could  be  kept  alive  by  means  of  the  auto- 
matically working  pulmotor  for  as  long  as  one  hour.  The 
animal  remained  in  fairly  good  condition,  had  about  thirty 


APPENDIX  275 

respirations  per  minute,  and  no  air  entered  the  stomach.  In 
another  dog  the  usual  laboratory  method  of  artificial  respira- 
tion (inflation  of  the  lungs)  had  to  be  substituted  for  two  to 
three  minutes  every  eight  or  ten  minutes  in  order  to  keep  the 
animal  alive.  The  respiratory  movements  would  go  on  with 
the  pulmotor  regularly  for  a  while,  and  then  they  would  begin 
to  change  from  a  slow  to  a  rapid  rhythm,  and  the  pulse  would 
gradually  become  dangerously  slow.  In  two  other  animals 
the  pulmonary  respiration  would  continue  regularly  at  one 
position  of  the  head,  but  stop  at  the  slightest  change  from  that 
position.  On  other  occasions  changes  in  the  respiration  would 
occur  without  any  visible  cause.  In  the  majority  of  the  ani- 
mals respiration  could  not  be  kept  up  even  for  five  minutes 
when  left  to  the  automatic  activity  of  the  apparatus.  The  re- 
sult was  evidently  better  when  the  respiratory  alternations  of 
the  machines  were  guided  by  hand,  so  as  to  have  sixteen  to 
twenty  respiratory  cycles  per  minute.  But  even  under  these 
circumstances  the  circulation  could  rarely  be  kept  up  in  a  nor- 
mal state  for  longer  than  twelve  or  fifteen  minutes. 

When  the  thorax  was  opened  the  lungs  were  seen  becom- 
ing gradually  smaller  and  smaller.  In  a  young  dog  and  in  a 
cat  the  unopened  thorax  was  also  observed  getting  smaller  as 
soon  as  respiration  was  started  by  the  pulmotor.  An  equili- 
brium was  soon  reached,  and  the  respiratory  changes  in  the 
size  of  the  thorax  apparently  took  place  then  within  the  normal 
expiratory  diameters.  The  respiratory  changes  in  the  tracheal 
manometer  would  often  be  only  from  a  more  to  a  less  nega- 
tive pressure,  never  positive.  The  changes  in  the  tracheal 
pressure  amounted  often  only  to  30  or  40  millimeters  of  water. 
When  the  thorax  was  opened,  after  the  pulmotor  had  been 
used  for  a  while,  the  lungs  often  presented  an  uneven  appear- 
ance, small  collapsed  areas  alternating  with  much  dilated  areas. 
After  connecting  with  the  ordinary  laboratory  respiratory  ap- 


276  APPENDIX 

paratus  this  unevenness  soon  disappeared.  When  the  pulmotor 
was  connected  directly  with  a  tracheal  tube  respiration  was 
kept  up  in  a  more  reliable  way,  especially  in  cats  and  rabbits. 
\\'hen  regulating  the  respiration  by  hand  air  often  entered  the 
stomach.  Pressure  upon  the  trachea  or  larynx  rather  pre- 
vented the  entrance  of  air  into  the  lungs  and  increased  its  en- 
trance into  the  stomach. 

These  observations  on  animals  indicate  that  there  are  two 
factors  which  interfere  with  the  efficiency  of  the  pulmotor  as 
a  reliable  device  for  artificial  respiration.  The  first  is  its  auto- 
matic activity  and  the  ease  with  which  inspiration  is  turned 
into  expiration.  Inflation  and  deflation  of  a  bag — the  method 
used  by  agents  to  demonstrate  the  action  of  the  pulmotor — is 
deceptive,  because  the  bag,  unlike  the  air  passages  of  the  body, 
offers  no  resistance  until  full.  As  soon  as  the  inspiratory  blast 
meets  an  obstacle  in  the  air  passages  it  is  automatically  cut  off 
and  turned  into  expiration,  and  thus  frequently  no  efficient 
inspirations  are  performed.  In  lower  animals,  certainly,  the 
blast  often  meets  obstacles  while  passing  from  the  pharynx 
into  the  alveoli,  and  the  inspiratory  pressure  of  the  automati- 
cally working  pulmotor  is  in  many  cases  insufficient  to  over- 
come them.  AA^hen  guided  by  hand  the  inspiratory  pressure  is 
permitted  to  increase;  hence  the  greater  efficiency  under  these 
circumstances. 

The  second  harmful  factor  brought  out  by  these  experi- 
ments is  the  performance  of  expiration  by  suction.  In  normal 
respiration  expiration  is  accomplished  by  a  power  which  does 
not  suck,  but  drives  the  air  out  by  the  elasticity  of  the  dis- 
tended or  compressed  tissues,  aided,  sometimes,  by  muscular 
contraction.  The  finer  bronchioles  have  no  cartilages;  when 
air  is  sucked  out  from  the  trachea  and  larger  bronchi,  the 
bronchioles  are  liable  to  close  before  the  suction  reaches  the 
alveoli.     Furthermore,  when  the  air  is  actively  sucked  out  the 


APPENDIX  277 

walls  of  many  of  the  bronchioles  and  alveoli  are  liable  to  col- 
lapse and  stick  together,  so  that  the  next  inspiratory  pressure, 
which  is  barely  sufficient  to  overcome  the  elasticity  of  the  lung, 
is  not  strong  enough  to  overcome  the  resistance  offered  by  the 
adherent  surfaces.  The  successive  additional  respiratory 
changes  may  therefore  take  place  largely  in  the  bronchial  tree 
and  not  sufficiently  in  the  alveoli;  that  is,  there  may  be  a  les- 
sened exchange  of  gases  while  the  movements  of  the  thorax 
still  simulate  normal  respiration.  Hence  failure  of  the  circu- 
lation ensues  with  diminution  of  the  size  of  the  lungs  and  the 
thorax.  This  obstacle,  however,  need  not  remain  permanent. 
After  several  attempts  an  inspiration  may  finally  succeed  in 
driving  air  into  all  the  isolated  alveoli  or  into  many  groups 
of  them;  hence  the  occurrence  of  changes  in  the  respiratory 
rhythm  of  some  animals,  and  the  uneven  appearance  of  the 
surface  of  the  lungs  in  others.  On  the  other  hand,  in  some 
one  or  other  individual  animal  the  passage  into  the  larynx, 
the  organization  of  the  bronchial  tree,  etc.,  appear  to  be  well 
adapted  to  the  rhythm  of  the  pulmotor,  which  therefore  may 
be  capable  of  keeping  up  the  respiration  of  such  an  animal 
even  when  it  is  completely  curarized. 

Finally  observation  shows  that  the  entrance  of  air  into  and 
escape  of  air  from  the  stomach  may  cause  movements  of  the 
thorax  which  simulate  respiration  while  actually  no  air  enters 
or  leaves  the  bronchial  tree. 

Upon  the  basis  of  these  observations  the  conclusion  was 
reached  that  the  automatic  mechanism  of  the  pulmotor,  while 
being  an  ingenious  technical  contrivance,  instead  of  assuring 
artificial  respiration,  may  interfere  greatly  with  its  efficiency, 
because  it  is  liable  to  cut  off  inspiration  prematurely.  The 
management  of  the  changes  in  the  phases  bf  respiration  when 
the  pulmotor  is  worked  by  hand  is  more  reliable.  But  when 
handled  in  this  manner  no  practical  difference  exists  between 


278  APPEXDIX 

the  pulmotor  and  the  Dr.  Brat  apparatus,  at  least  so  far  as  the 
mechanism  is  concerned.  In  both  machines,  howe^-er,  the  ex- 
piration is  accompHshed  by  suction,  which  is  again  a  serious 
defect.  The  sucking  action  of  these  devices  might  prove  even 
dangerous  if  they  were  used  continuously  to  keep  up  respira- 
tion for  a  long  time.  In  connection  with  the  experiments  on 
animals,  which  in  most  instances  could  be  continued  a  rela- 
tively short  time  only,  it  is  pertinent  to  recall  the  fact  that  the 
successes  reported  by  the  physicians  connected  with  the  Car- 
negie Steel  Corporation  were  obtained  in  cases  in  which-  the 
pulmotor  was  used  for  a  short  period  only. 

That  both  machines  are  heavy,  expensive,  and  waste  a 
great  deal  of  oxygen,  with  which  they  are  not  sufficiently  pro- 
vided, are  minor  points  in  their  disfavor.  The  absence  of 
careful  analysis  of  the  action  of  the  pulmotor  in  clinical  cases, 
the  ease  with  which  it  may  fail  to  cause  inflation  of  the  lungs, 
the  bad  effects  which  occur  if  its  sucking  action  in  expiration 
is  permitted  to  continue  for  a  long  period,  are  all  important 
considerations  which  should  be  taken  into  account  in  judging 
the  instrument.  A\'hen  they  are  taken  into  account  the  high 
credit  given  the  machine  in  popular  opinion  seems  not  to  have 
a  substantial  foundation. 

In  view  of  the  facts  obtained  by  a  study  of  the  Dr.  Brat 
apparatus  and  the  pulmotor  the  members  of  the  subcommittee 
agreed  upon  the  following  suggestions :  In  cases  without  any 
respiration  the  pulmotor  should  be  used  only  when  guided  by 
hand  and  then  not  faster  than  twelve  to  fifteen  complete  res- 
pirations per  minute;  when  left  to  run  automatically  it  is  liable 
to  be  inefiicient  and  dangerously  deceptive.  Because  of  suction 
on  the  lungs  neither  the  pulmotor  nor  the  Dr.  Brat  apparatus 
should  be  used  longer  than  for  a  few  minutes  (five  to  six)  at 
a  time,  and,  if  there  be  no  better  contrivance,  should  be  alter- 
nated with  the  Schafer  method  combined  with  oxygen  inhala- 


APPENDIX  279 

tion.  In  cases  of  slow  and  stertorous  breathing,  however,  both 
machines  can  probably  be  used  for  a  longer  time  with  benefit 
and  without  danger. 

Dr.  Meltzer's  Mechanical  Method  of  ArtiUcial  Respiration 

About  a  year  ago  Dr.  Meltzer  published  a  brief  communi- 
cation on  pharyngeal  insufflation  as  a  method  of  artificial 
respiration.  It  was  based  upon  the  following  considerations : 
When  air  is  insufflated  into  the  pharynx  it  may  escape  from 
there  through  the  nose,  the  mouth,  into  the  stomach,  and  into 
the  lungs.  In  order  to  have  it  enter  the  lungs  the  facilities 
for  escape  through  the  other  exits  must  be  prevented  or  greatly 
reduced.  The  escape  through  the  nose  was  practically  pre- 
vented by  the  elastic  tube  in  the  pharynx  which  raised  the  soft 
palate  and  thus  shut  off  the  exit  into  the  nasopharynx.  The 
escape  through  the  mouth  was  sufiffciently  restricted  by  apply- 
ing pressure  under  the  chin. 

The  evil  effects  of  the  entrance  of  air  into  the  stomach 
were  met  by  two  methods  :  In  one  a  tube  was  introduced  into 
the  stomach;  this  tube  restricted  on  the  one  hand  the  entrance 
of  air  into  the  esophagus,  and  on  the  other  hand  readily  re- 
moved the  surplus  air  from  the  stomach.  In  the  other  method 
a  heavy  weight  was  placed  upon  the  abdomen,  which  effec- 
tively restricted  the  entrance  of  air  into  the  stomach  and  pre- 
vented its  passage  into  the  intestines.  The  inspirations  were 
thus  provided  for  by  rhythmical  insufflations  through  a  cathe- 
ter, the  inner  end  of  which  was  placed  in  the  pharynx,  while 
the  outer  end  was  connected  with  hand  bellows  or  a  respiratory 
apparatus.  The  expirations  took  place  during  the  pauses  be- 
tween the  insufflations  by  the  elastic  recoil  of  the  extended 
ribs  and  of  the  compressed  abdominal  viscera.  The  expired 
air  escaped  through  the  mouth  alongside  the  tube.  Experi- 
ments on  curarized  animals  (dogs,  cats,  rabbits,  and  monkeys) 


28o  APPENDIX 

have  shown  definitely  that  pharyngeal  insufflation  as  described 
above  is  capable  of  keeping  up  efficient  artificial  respiration  for 
many  hours. 

When  Dr.  Meltzer  later  attempted  to  apply  this  method  on 
human  beings  he  found  that  it  failed  to  work ;  here  the  insuf- 
flated air  escaped  so  readily  through  nose  and  mouth  that  the 
remaining  pressure  was  insufficient  to  produce  an  inspiration. 
Furthermore,  pharyngeal  insufflation  in  its  original  form  did 
not  sufficiently  provide  for  getting  rid  of  the  expired  air.  Dur- 
ing the  past  year  the  method  has  been  improved,  and  as  a  re- 
sult the  following  simple  and  effective  devices  are  suggested 
(see  Journal  of  the  American  Medical  Association,  19 13,  Ix, 
p.  1407)  : 

Two  methods  may  be  used  to  convey  the  air  to  the  respira- 
tory passages — the  pharyngeal  and  the  mask  methods.  In  the 
pharyngeal  method  insufflation  takes  place  through  a  metal 
pharyngeal  tube  which  has  been  made  to  fit  the  human  anat- 
omy. The  tube  (see  Fig.  i)  measures  about  four  centimeters 
transversely  and  three  centimeters  vertically;  the  lower 
(tongue)  side  is  flat,  while  the  upper  (palate)  side  is  round. 
The  upper  side  is  longer  than  the  lower.  When  the  tube  is  in- 
serted the  end  of  the  upper  side  should  touch  the  posterior  wall 
of  the  pharynx,  while  the  lower  side  terminates  at  about  the 
root  of  the  tongue.  The  entrance  to  the  nasopharynx  is  thus 
closed,  while  air  enters  freely  into  the  lower  pharynx.  The 
size  of  the  tube  almost  completely  prevents  the  escape  of  *air 
through  the  mouth.  The  outer  end  of  the  tube  carries  a  neck 
for  connection  with  the  respiratory  apparatus,  and  has  a  hole 
through  which  a  well-fitting  tube  can  be  introduced  into  the 
stomach.  When  not  used  this  hole  is  kept  closed  by  a  movable 
plate. 

The  neck  of  the  pharyngeal  tube  is  connected  by  means  of 
a  short  piece  of  strong  rubber  tubing  with  the  proximal  end 


APPENDIX 


281 


of  the  "respiratory  valve"  (see  Fig.  i).  This  Httle  device  is  a 
metal  cylinder  containing  a  valve  which  is  readily  moved  by  a 
ring  outside.  When  the  ring  is  moved  to  the  right,  air  or  oxy- 
gen passes  through  the  cylinder  in  the  direction  of  the 
pharynx,  thus  causing  an  inspiration.  When  the  ring  is  moved 
to  the  left,  the  cylinder  is  closed  for  the  inspiratory  air  or  oxy- 
gen, and  instead  an  opening  is  made  above  the  valve  through 


Fig.  I. — Arrangement  of  the  Meltzer  Apparatus  rbR  Artificial  Res- 
piration. P.  T.,  pharyngeal  tube.  R.  V.,  respiratory  valve.  The  ring 
turns  the  valve;  turning  to  the  right  (facing  the  pharyngeal  tube) 
brings  an  inspiration  and  to  the  left  brings  an  expiration.  B,  foot- 
bellows.  S.  v.,  safety-valve.  The  bottle  of  the  safety-valve  should 
be  shorter  and  have  a  wider  diameter  than  the  one  in  the  figure ;  it  is 
less  likely  to  turn  over.  S.  T.,  stomach-tube  introduced  through  the 
opening  in  the  pharyngeal  tube. 

which  the  expiratory  air  can  readily  escape.  The  cylinder  can 
be  conveniently  held  in  the  hand  and  the  ring  moved  to  right 
and  left  by  the  thumb.  The  distal  end  of  the  respiratory  valve 
is  connected  either  with  foot  bellows,  which  give  practically  a 
continuous  air  current,  or  with  an  oxygen  tank.  A  safety 
valve  is  interpolated  between  the  source  of  pressure  and  the 
respiratory  valve;  some  heavy  weight  and  a  strong  belt  to 
compress  the  abdomen  complete  the  outfit. 


282 


APPENDIX 


The  procedure  is  as  follows:  (see  Fig.  2)  (i)  Heavy 
weights  should  be  placed  upon  the  abdomen,  (The  pressure 
may  be  reinforced  by  a  belt.  A  broad  belt  alone  is  insuffi- 
cient.) (2)  The  tongue  should  be  pulled  out  by  means  of 
proper  tongue  forceps,  and  the  pharyngeal  tube  inserted  as  far 
as  it  may  go.  For  the  sake  of  being  in  readiness,  the  respira- 
tory valve  should  be  kept  attached  to  the  pharyngeal  tube. 


0  ^  V  li  t   N 

Fig.  2. — Meltzer  Apparatus  in  Use.  M.,  mask.  Infl.,  tube  for  inflating 
the  rubber  ring  around  the  rim  of  the  mask.  R.  V.,  respiratory  valve. 
S.  v.,  safety-valve.  An  oxygen  cylinder  provides  here  the  insufflation 
pressure.  The  figure  shows  also  the  weight  on  the  abdomen  and  the 
belt  around  it. 

The  connecting  tube  should  be  strong  and  short  (the  latter  in 
order  to  have  the  expiratory  dead  space  as  short  as  possible. 
(3)  The  distal  end  of  the  respiratory  valve  should  be  con- 
nected with  the  apparatus  supplying  the  pressure,  i.  e.,  bellows 
or  oxygen  tank  plus  safety  valve.  The  respiratory  valve 
should  now  be  turned  for  two  to  three  seconds  to  the  right 
and  as  long  to  the  left. 

Respiration  should  not  be  repeated  more  frequently  than 
twelve  to  fifteen  times  per  minute.  In  case  of  necessity  the 
same  man  may  work  with  his  hand  the  respiratory  valve  and 


APPENDIX  283 

with  his  foot  the  bellows ;  and  if  there  are  no  weights  at  hand 
he  may  rest  part  of  his  own  weight  upon  the  abdomen  of  the 
victim.  In  case  of  collapse  and  suspension  of  respiration  dur- 
ing an  abdominal  operation,  when  no  weights  can  be  placed 
upon  the  abdomen,  a  large  stomach  tube  (33,  French  size) 
should  be  pushed  through  the  opening  in  the  pharyngeal  tube ; 
it  will  slip  down  readily  into  the  stomach  and  render  the  neces- 
sary service.  It  would  probably  be  better  to  do  this  in  every 
case,  but  untrained  laymen,  who  in  most  cases  may  have  to 
render  the  first  aid,  might  hesitate  to  insert  the  stomach  tube. 
The  pressure  upon  the  abdomen  may  likewise  render  good 
service  to  a  failing  circulation.  Experiments  on  lower  animals 
show  that  in  failing  circulation  strong  pressure  upon  the  ab- 
domen raises  the  blood  pressure  effectively  and  fills  the  heart, 
and  thus  also,  of  course,  may  benefit  the  medulla. 

When  a  suitable  pharyngeal  tube  is  not  at  hand,  artificial 
respiration  may  be  executed  with  the  aid  of  a  well-fitting  face 
mask  provided  with  a  tube  for  connection  with  the  respiratory 
valve.  All  other  parts  needed  for  artificial  respiration  are  the 
same  as  with  the  pharyngeal  tube,  except  that  no  stomach  tube 
can  be  introduced.  No  time  should  be  lost  in  fastening  the 
mask;  it  should  be  pressed  to  the  face  with  one  hand,  while 
the  other  hand  is  working  the  respiratory  valve,  until  more 
help  is  obtained. 

Both  methods  have  been  tried  on  numerous  animals  and 
have  been  demonstrated,  keeping  animals  alive  for  many  hours 
while  under  the  exacting  conditions  of  curare  and  ether  and 
of  opened  thorax.  The  methods  have  also  been  proved  effi- 
cient in  causing  inflation  of  the  lungs  in  cadavers  in  rigor  or 
after  hours  on  ice.  Even  when  rigidity  of  the  walls  obscured 
external  movements  auscultation  demonstrated  clearly  the  en- 
trance of  air  into  the  lungs.  Especially  in  cases  dying  with 
pulmonary  edema,  the  rhythmical  crackling  which  could  be 


284  APPENDIX 

readily  heard  was  very  convincing.  The  pharyngeal  tube 
seemed  to  work  somewhat  more  efficiently  than  the  mask 
method. 

The  apparatus  which  Dr.  ]\Ieltzer  has  devised  has  the  fol- 
lowing commendable  features  :  ( i )  Its  positive  action  is  de- 
termined by  the  operator,  and  not  left  to  a  mechanism  which 
may  fail  to  operate.  (2)  It  is  free  from  the  sucking  action 
during  expiration.  Expiration  results  from  the  natural  recoil 
of  the  disturbed  parts.  (3)  It  is  light.  (4)  It  is  relatively 
inexpensive.  (5)  It  is  simple.  (6)  It  embodies  in  a  form 
which  can  be  used  by  laymen  a  method  of  artificial  respiration 
which  has  been  employed  for  many  years  in  scores  of  labora- 
tories and  on  thousands  of  animals,  and  is  known  to  be  effec- 
tive and  free  from  danger. 

These  are  virtues  which  stand  out  prominently  at  points 
where  present  commercial  devices  are  in  fact  most  defective. 
The  Commission  therefore  recommends  this  apparatus  as  a 
satisfactory  means  of  continuing  artificial  respiration  and  sug- 
gests that  in  cases  of  suspended  breathing  the  modified  prone 
pressure  method  be  supplemented  as  soon  as  possible  by  the 
use  of  the  IMeltzer  apparatus. 

'Drs.  W.  B.  Cannox,  Chairman 
George  W.  Crile 
Yaxdell  Henderson 
S.  J.  AIeltzer 
Edward  Antony  Spitzka 
A.  E.  Kennelly 
Elihu  Thomson 
\Y.  C.  L.  Eglin 
W.  D.  AA'eaver,  Secretary 


Members  of  the 
Commission 


APPENDIX  285 

REPORT  OF  THE   COMMISSION   ON  RESUSCITA- 
TION  FROM   MINE   GASES 

The  Committee  on  Resuscitation  from  Mine  Gases,  which 
was  appointed  in  June,  19 12,  has  visited  mines  in  the  soft  and 
hard-coal  regions  in  Pennsylvania,  has  met  and  had  discus- 
sions with  men  engaged  in  first-aid  work,  has  witnessed  dem- 
onstrations of  methods  of  giving  artificial  respiration,  has  ex- 
amined critically  these  methods,  has  studied  old  and  new  de- 
vices to  maintain  breathing,  and  as  a  result  herewith  offers  a 
review  of  its  findings,  and  some  suggestions  which,  the  Com- 
mittee believes,  will  increase  the  chances  of  reviving  victims 
of  mine  accidents. 

Two  classes  of  accidents  requiring  methods  of  resuscita- 
tion occur  in  mines  :  ( i )  shocks  from  the  electric  current, 
and  (2)  poisoning  or  suffocation  by  mine  gases.  Although 
the  present  Committee  was  not  asked  to  consider  means  of 
resuscitating  victims  of  electric  shock,  most  of  its  members 
have  also  been  members  of  a  Commission  on  Resuscitation 
from  Electric  Shock  and  have  had  to  deal  with  both  problems. 
And  in  some  respects  the  matters  of  primary  importance  in 
both  conditions  are  the  same.  Thus  in  electric  shock  respira- 
tion may  be  suspended  or  the  heart  may  become  ineffective 
from  weakness  or  fibrillary  contraction,  and  in  consequence 
the  body  is  not  supplied  with  oxygen.  Lack  of  oxygen  in  the 
tissues  is  also  the  fundamental  difficulty  in  persons  overcome 
by  mine  gases.  Deprivation  of  oxygen  for  about  ten  minutes 
may  injure  irremediably  some  of  the  most  essential  nerve  cells 
of  the  brain.  In  both  conditions,  therefore,  the  prime  neces- 
sity for  promoting  survival  is  the  prompt  supply  of  oxy- 
genated blood.  From  this  it  follows  that,  when  spontaneous 
breathing  has  stopped,  methods  of  artificial  respiration  are 
the  most  valuable  means  of  bringing  back  a  normal  condi- 


286  APPENDIX 

tion  of  the  body.  And  yet  not  all  methods  are  equally  useful 
for  this  purpose,  even  though  they  may  cause  an  equal  ventila- 
tion of  the  lungs.  The  reasons  for  this  statement  will  become 
clear  if  we  consider  the  various  conditions  of  accident  which 
bring  about  a  serious  diminution  of  oxygen  in  the  tissues. 

Simple  Asphyxiation. — If  in  electric  shock  the  nervous  con- 
trol of  the  muscles  of  respiration  is  temporarily  paralyzed,  the 
heart  continues  for  a  few  minutes  to  pump  blood  through  the 
body,  but  because  the  blood  is  not  supplied  with  oxygen  the 
heart  soon  stops  beating  effectively  and  the  victim  dies  of 
asphyxia.  The  same  result  follows  in  drowning,  and  likewise 
in  sufifocation  when  carbon  dioxid  or  excess  of  nitrogen  has 
largely  replaced  the  oxygen  of  the  atmosphere.  In  such  cases 
artificial  respiration,  in  which  the  lungs  are  at  once  adequately 
supplied  with  ordinary  air,  is  a  sufficient  treatment. 

Carbon  Monoxid  Poisoning. — If  the  victim  has  been  over- 
come by  carbon  monoxid  (CO),  the  principal  poisonous  sub- 
stance in  illuminating  gas  and  in  the  gases  after  mine  explo- 
sions, the  case  is  somewhat  different.  The  poisonous  charac- 
ter of  this  substance  depends  primarily  upon  its  strong  chem- 
ical affinity  for  the  hemoglobin  of  the  blood — the  substance 
which  normally  transports  from  the  lungs  through  the  body 
the  oxygen  used  by  the  tissues.  The  affinity  of  CO  for  hemo- 
globin is  between  two  and  three  hundred  times  as  great  as 
that  of  oxygen  for  hemoglobin.  Carbon  monoxid,  however, 
does  not  form  a  permanent  combination  with  hemoglobin  any 
more  than  does  oxygen,  but  unites  with  it  or  separates  from  it 
according  to  the  law  of  mass  action  in  amounts  determined  by 
the  partial  pressure  of  oxygen  and  CO  in  the  atmosphere 
breathed.  A\'hen  a  miner  after  a  dust  explosion,  or  a  person 
in  a  room  into  which  gas  is  escaping,  breathes  for  a  number  of 
hours  an  atmosphere  containing  a  small  amount  of  CO,  a  con- 
dition of  partial   saturation  of  the  hemoglobin   is  attained. 


APPENDIX  287 

Thus,  if  air  containing  only  o.i  per  cent,  of  CO  is  breathed 
continuously,  it  will,  because  of  its  great  affinity,  unite  with 
about  half  of  the  hemoglobin  of  the  blood.  The  hemoglobin 
combined  with  CO  cannot  transport  oxygen,  and  the  subject 
is  thus  brought  into  a  condition  of  partial  suffocation.  Since 
the  demands  of  the  tissues  for  oxygen  vary  with  their  activity 
the  first  effect  is  a  lessened  ability  to  work.  Walking  becomes 
difficult,  then  impossible;  after  a  time  consciousness  is  lost; 
and  ultimately,  unless  the  subject  is  removed  from  the  at- 
mosphere, death  from  asphyxiation  ensues. 

If  before  death  the  subject  is  brought  into  an  atmosphere 
free  from  CO,  the  combination  between  this  gas  and  hemo- 
globin immediately  begins  to  break  up.  The  separation  is 
more  rapid  if  pure  oxygen  is  breathed.  Even  if  merely  air  is 
breathed  the  hemoglobin  may  thus  after  ten  or  fifteen  minutes 
be  freed  to  a  degree  sufficient  to  transport  the  necessary 
amount  of  oxygen,  i.  e.j,  the  percentage  saturation  of  hemo- 
globin with  CO  may  be  reduced  below  the  danger  point.  Usu- 
ally within  six  or  eight  hours  practically  all  the  CO  is  elimi- 
nated, and  the  hemoglobin  is  then  just  as  efficient  for  the  trans- 
portation of  oxygen  as  if  the  subject  had  never  been  poisoned. 

In  spite  of  the  elimination  of  CO,  however,  in  a  large  per- 
centage of  cases  the  subject  does  not  recover.  He  may  die 
during  the  next  few  days,  or  weeks,  or  may  continue  to  live 
with  impaired  sight  or  disturbed  mentality.  These  effects, 
however,  according  to  available  evidence,  are  in  the  main  not 
due  to  direct  poisonous  action  of  CO,  but  to  deprivation  of 
oxygen.  Men  employed  in  gas  works  and  constantly  breathing 
amounts  of  CO  insufficient  to  interfere  with  oxygen  transpor- 
tation by  the  blood  do  not  show  cumulative  ill  effects,  and  in 
animals  which  have  no  hemoglobin  CO  is  an  entirely  inert  gas. 
Thus  insects  in  an  atmosphere  containing  even  a  high  per- 
centage of  the  gas  are  quite  unaffected  so  long  as  there  is  a 


288  APPENDIX 

percentage  of  oxygen  present  reasonably  equivalent  to  that  in 
the  air.  Furthermore,  as  Haldane  has  shown,  a  mouse  just 
overcome  by  CO  recovers  quickly  and  will  even  run  about,  if 
exposed  to  two  atmospheres  of  oxygen  in  a  pressure  chamber, 
so  that  a  quantity  sufficient  to  supply  bodily  needs  can  be  car- 
ried by  the  blood  in  simple  solution.  Such  a  mouse  removed  to 
air  may  suffer  a  recurrence  of  symptoms  if  it  has  not  breathed 
the  oxygen  long  enough  to  set  free  from  CO  a  sufficient 
amount  of  its  hemoglobin.  In  persons  dying  as  the  result  of 
CO  poisoning  the  blood,  if  they  have  survived  more  than 
twelve  hours,  usually  contains  no  noteworthy  amount  of  this 
gas.    What,  then,  is  the  cause  of  death? 

At  autopsy  such  cases  exhibit  distinct  areas  of  cell  de- 
generation in  the  brain.  From  this  and  other  evidence,  it  is 
clear  that  the  fatalities  are  the  result  of  an  insufficient  oxygen 
supply  during  the  time  the  subject  was  breathing  the  at- 
mosphere containing  CO.  If  the  pathological  changes  are  well 
started  no  amount  of  oxygen,  nor  any  other  treatment,  can 
restore  the  damaged  nerve  cells.  If  they  have  not  been  much 
damaged,  recovery  may  follow  even  without  therapeutic  as- 
sistance. There  is,  perhaps,  no  class  of  cases  of  disease,  or 
any  form  of  poisoning,  in  which  it  is  so  difficult  for  even  an 
expert  to  decide  with  any  degree  of  accuracy  whether  such 
treatment  as  was  given  played  any  considerable  part  in  the  re- 
covery of  the  patient.  A  large  number  of  cases  of  illuminat- 
ing gas  poisoning  which  happen  in  all  American  cities  in  which 
a  high  percentage  of  water  gas  is  used  recover  spontaneously. 
The  subject  is  found  in  the  morning  in  a  room  smelling 
strongly  of  gas,  unconscious,  breathing  stertorously,  with  eyes 
half  closed  and  rolling,  and  with  teeth  frequently  clenched. 
The  person  making  the  discovery  turns  off  the  gas,  opens  the 
windows,  and  telephones  for  the  doctor  and  for  the  ambu- 
lance.   By  the  time  such  assistance  arrives  the  mere  breathing 


APPENDIX  289 

of  fresh  air  has  already  reduced  the  amount  of  CO  in  the  blood 
so  that  the  hemoglobin  set  free  is  sufficient  to  transport  the 
oxygen  that  the  patient  needs.  If  the  degenerative  process  in 
the  brain  cells  has  not  been  started  before  the  patient  was  dis- 
covered, recovery  ensues.  If,  on  the  other  hand,  the  amount 
of  hemoglobin  combined  with  CO  exceeded  a  figure  between 
60  and  70  per  cent.,  so  that  only  30  or  40  per  cent,  of  the  hemo- 
globin was  available  for  the  transport  of  oxygen,  and  if  the 
patient  has  been  in  this  condition  for  half  an  hour  or  more, 
degenerative  processes  and  death  or  serious  nervous  or  mental 
impairment  will  certainly  follow.  At  the  time  when  the  pa- 
tient is  discovered,  or  even  for  an  hour  or  more  thereafter,  it 
is  quite  impossible  for  anyone  to  state  whether  the  degree  of 
poisoning  has  passed  the  danger  point.  The  subject  may  be 
profoundly  unconscious,  and  not  only  apparently,  but  actually, 
at  the  point  of  death,  and  yet,  if  the  length  of  time  during 
which  the  deficient  oxygenation  of  the  brain  cells  has  contin- 
ued has  not  been  too  great,  a  half  hour  in  the  fresh  air  will  be 
enough  to  effect  an  apparently  remarkable  recovery.  It  is  a 
natural  mistake  for  the  attending  family  or  ambulance  physi- 
cian to  regard  the  recovery  as  due  to  his  efforts,  when,  as  a 
matter  of  fact,  it  might  have  occurred  if  he  had  done  nothing 
whatever.  It  is  altogether  probable  that  many  of  the  brilliant 
recoveries,  claimed  in  the  newspapers  as  due  to  this  or  that  de- 
vice, occurred  in  the  victim's  breathing  spontaneously,  and 
therefore  not  requiring  artificial  respiration. 

As  in  simple  asphyxia,  however,  so  also  in  carbon  monoxid 
poisoning,  there  is  a  critical  period  beyond  which  recovery  is 
out  of  the  question.  It  is  of  the  utmost  importance  in  every 
case,  therefore,  to  supply  the  cells  with  oxygen  as  soon  as  pos- 
sible, on  the  chance  that  the  critical  period  has  not  been 
reached.  And  because  the  surrender  of  carbon  monoxid  by 
hemoglobin    proceeds    more    rapidly    when    pure    oxygen    is 


290  APPENDIX 

breathed,  and,  further,  because  breathing  pure  oxygen  increases 
the  supply  to  the  tissues  by  increasing  the  amount  dissolved 
in  the  blood,  the  proper  treatment  for  CO  poisoning  is  the 
breathing  of  oxygen.  If  the  victim,  though  unconscious,  is 
breathing  in  nearly  the  normal  manner,  he  may  be  allowed  to 
inspire  the  oxygen  himself.  If  the  breathing  is  slow  and  ir- 
regular, or  if  it  has  stopped  entirely,  as  may  be  the  case  in  sud- 
den exposure  to  concentrated  CO,  artificial  respiration  should 
be  performed,  but  with  the  administration  of  oxygen. 

In  both  simple  asphyxia  and  in  asphyxia  from  CO2  and 
CO,  therefore,  artificial  respiration  may  be  essential  to  recov- 
ery of  the  victim.  A  consideration  of  the  efficiency  of  dif- 
ferent means  of  artificial  respiration  is  obviously  important. 
Two  general  methods  of  producing  artificial  respiration  are 
advocated :  ( i )  the  manual  method,  which  can  be  utilized 
wherever  the  air  is  good  by  any  intelligent  adult,  and  (2)  the 
mechanical  method,  by  which  the  lungs  are  inflated  by  pump- 
ing air  or  oxygen  into  them.  These  two  general  methods  will 
be  considered  in  turn. 

(Note. — The  description  of  these  methods  has  already 
been  given  in  the  Report  of  the  Commission  on  Resuscitation 
from  Electric  Shock.) 


Members  of  the 
Commission 


Drs.  W.  B.  Cannon,  Chairman 
George  W.  Chile 
Joseph  Erlanger 
Yandell  Henderson 
S.  J.  Meltzer  ' 


APPENDIX  291 

RULES   FOR  RESUSCITATION  FROM   ELECTRIC 
SHOCK 

RECOMMENDED   BY 
COMMISSION   ON   RESUSCITATION   FROM  ELECTRIC 

SHOCK ' 

Dr.  W.  B.  Cannon,  Chairman 

Professor  of  Physiology,  Harvard  University 

Dr.  George  W.  Crile 

Professor  of  Surgery,  Western  Reserve  University 

Dr.  Yandell  Henderson 

Professor  of  Physiology,  Yale  University 

Dr.  S.  J.  Meltzer 

Head  of  Department  of  Physiology  and  Pharmacology, 
Rockefeller  Institute  for  Medical  Research 

Dr.  Edw.  Anthony  Spitzka 

Director   and   Professor   of   General   Anatomy,   Daniel 
Baugh  Institute  of  Anatomy,  Jefferson  Medical  College 

Mr.  W.  C.  L.  Eglin 

Past-President,  National  Electric  Light  Association 

Dr.  a.  E.  Kennelly 

Professor  of  Electrical  Engineering,  Harvard  University 

Dr.  Elihu  Thomson 

Electrician,  General  Electric  Company 

Mr.  W.  D.  Weaver,  Secretary 
Editor,  Electrical  World 


Copyright,  19 12 

National  Electric  Light  Association 

Permission  to  reprint  will  he  granted  on  application 

1  Reprinted  by  permission. 


292  APPENDIX 

Superintendents,  foremen,  and  others  having 
charge  of  men  are  advised  to  give  practical  instruc- 
tions and  demonstrations  on  the  use  of  these  rules  to 
all  old  and  new  employees. 

Physicians  who  may  be  called  upon  in  cases  of 
shock  should  be  given  copies  of  these  instructions  and, 
where  practicable,  placed  in  communication  with  the 
physician  of  the  electrical  company. 


The  prone-pressiire  method  of  artificial  respiration  de- 
scribed in  these  rules  {Section  III)  is  equally  applicable,  after 
clearing  the  mouth  and  throat  of  froth,  to  resuscitation  of  the 
apparently  drozmied,  and  also  to  cases  of  suspended  respira- 
tion due  to  inhalation  of  gas  or  to  other  causes. 

Treatment  for  Electric  Shock 

An  accidental  electric  shock  usually  does  not  kill  at  once, 
but  may  only  stun  the  victim  and  for  a  while  stop  his  breath- 
ing. 

The  shock  is  not  likely  to  be  immediately  fatal,  because : 

(a)  The  conductors  may  make  only  a  brief  and  imper- 
fect contact  with  the  body. 

(b)  The  skin,  unless  it  is  wet,  offers  high  resistance  to  the 
current. 

Hope  of  restoring  the  victim  lies  in  prompt  and  continued 
use  of  artificial  respiration.  The  reasons  for  this  statement 
are : 

(a)  The  body  continuously  depends  on  an  exchange  of 
air,  as  shown  by  the  fact  that  we  must  breathe  in  and  out 
about  fifteen' times  a  minute. 

(b)  If  the  body  is  not  thus  repeatedly  supplied  with  air, 
suffocation  occurs. 


APPENDIX  293 

(c)  Persons  whose  breathing  has  been  stopped  by  electric 
shock  have  been  reported  restored  after  artificial  respiration 
has  been  continued  for  approximately  two  hours. 

The  Schafer,  or  "prone  pressure"  method  of  artificial  res- 
piration, slightly  modified,  is  illustrated  and  described  in  the 
following  resuscitation  rules.  The  advantages  of  this  method 
are: 

(a)  Easy  performance;  little  muscular  exertion  is  re- 
quired. 

(b)  Larger  ventilation  of  the  lungs  than  by  the  supine 
method. 

(c)  Simplicity;  the  operator  makes  no  complex  motions 
and  readily  learns  the  method  on  first  trial. 

(d)  No  trouble  from  the  tongue  falling  back  into  the  air 
passage. 

(e)  No  risk  of  injury  to  the  liver  or  ribs  if  the  method  is 
executed  with  proper  care. 

Aid  can  be  rendered  best  by  one  who  has  studied  the  rides 
and  has  learned  them  by  practice  on  a  volunteer  subject. 

Instructions  for  Resuscitation 

Follow  these  Instructions  Even  if  Victim  Appears  Dead 
I. — Break  the  Circuit  Immediately 

I.  With  a  single  quick  motion  separate  the  victim  from 
the  live  conductor.  In  so  doing  avoid  receiving  a  shock  your- 
self. Many  have,  by  their  carelessness,  received  injury  in  try- 
ing to  disconnect  victims  of  shock  from  live  conductors. 

Observe  the  Following  Precautions 

(a)  Use  a  dry  coat,  a  dry  rope,  a  dry  stick  or  board,  or 
any  other  dry  nonconductor  to  move  either  the  victim  or  the 
wire,  so  as  to  break  the  electrical  contact.     Beware  of  using 


294  APPENDIX 

metal  or  any  moist  material.  The  victim's  loose  clothing,  if 
dry,  may  be  used  to  pull  him  away ;  do  not  touch  the  soles  or 
heels  of  his  shoes  while  he  remains  in  contact — the  nails  are 
dangerous. 

(b)  If  the  body  must  be  touched  by  your  hands,  be  sure 
to  cover  them  with  rubber  gloves,  mackintosh,  rubber  sheeting, 
or  dry  cloth;  or  stand  on  a  dry  board  or  on  some  other  dry 
insulating  surface.    If  possible,  use  only  one  hand. 

If  the  victim  is  conducting  the  current  to  ground,  and  is 
convulsively  clutching  the  live  conductor,  it  may  be  easier  to 
shut  off  the  current  by  lifting  him  than  by  leaving  him  on  the 
ground  and  trying  to  break  his  grasp. 

2.  Open  the  nearest  switch,  if  that  is  the  quickest  way  to 
break  the  circuit. 

3.  If  necessary  to  cut  a  live  wire,  vise  an  ax  or  a  hatchet 
with  a  dry  wooden  handle,  or  properly  insulated  pliers. 

II. — Send  for  the  Nearest  Doctor 

This  should  be  done  without  a  moment's  delay,  as  soon  as 
the  accident  occurs,  and  while  the  victim  is  being  removed  from 
the  conductor. 

The  doctors  entered  on  the  opposite  page  are  recom- 
mended : 

Name ^ 

Address 

Telephone  Call   

Name    

Address    

Telephone  Call   


APPENDIX  295 


Name   . 
Address 


Telephone  Call 


Name   . 
Address 


Telephone  Call 


III. — Attend  Instantly  to  Victim's  Breathing 

(i)  As  soon  as  the  victim  is  clear  of  the  live  conductor, 
quickly  feel  with  your  finger  in  his  mouth  and  throat  and  re- 
move any  foreign  body  (tobacco,  false  teeth,  etc.).  Then  be- 
gin artificial  respiration  at  once.  Do  not  stop  to  loosen  the  pa- 
tient's clothing;  every  moment  of  delay  is  serious. 

(2)  Lay  the  subject  on  his  belly,  with  arms  extended  as 
straight  forward  as  possible,  and  with  face  to  one  side,  so  that 
the  nose  and  mouth  are  free  for  breathing  (see  Figure  i). 
Let  an  assistant  draw  forward  the  subject's  tongue. 

If  possible,  avoid  so  laying  the  subject  that  any  burned 
places  are  pressed  upon. 

Do  not  permit  bystanders  to  crowd  about  and  shut  ofif  fresh 
air. 

(3)  Kneel  straddling  the  subject's  thighs  and  facing  his 
head;  put  the  palms  of  your  hands  on  the  loins  (on  the  mus- 
cles of  the  small  of  the  back),  with  thumbs  nearly  touching 
each  other,  and  with  fingers  spread  over  the  lowest  ribs  (see 
Figure  i). 

(4)  With  arms  held  straight,  swing  forward  slowly  so 
that  the  weight  of  your  body  is  gradually  brought  to  bear 


296 


APPENDIX 


FIG.  1— -INSPIRATION; 
PRESSURE    OFF. 


upon  the  subject  (see  Figure  2) .  This  operation,  which  should 
take  from  two  to  three  seconds,  in  list  not  be  violent — internal 
organs  may  be  injured.  The  lower  part  of  the  chest  and  also 
the  abdomen  are  thus  compressed,  and  air  is  forced  out  of  the 
lungs. 

(5)  Xow  immediately  swing  backward  so  as  to  remove 
the  pressure,  but  leave  your  hands  in  place,  thus  returning  to 
the  position  shown  in  Figure  i.     Through  their  elasticity  the 


APPENDIX  297 

chest  walls  expand  and  the  lungs  are  thus  supplied  with  fresh 
air. 

(6)  After  two  seconds  swing  forward  again.  Thus  repeat 
deliberately  twelve  to  fifteen  times  a  minute  the  double  move- 
ment of  compression  and  release — a  complete  respiration  in 
four  or  five  seconds.  If  a  watch  or  a  clock  is  not  visible,  fol- 
low the  natural  rate  of  your  own  deep  breathing — swinging 
forward  with  each  expiration,  and  backward  with  each  in- 
spiration. 

While  this  is  being  done,  an  assistant  should  loosen  any 
tight  clothing  about  the  subject's  neck,  chest,  or  waist. 

(7)  Continue  artificial  respiration  (if  necessary,  two 
hours  or  longer),  without  interruption,  until  natural  breathing 
is  restored,  or  until  a  physician  arrives.  Even  after  natural 
breathing  begins,  carefully  watch  that  it  continues.  If  it  stops, 
start  artificial  respiration  again. 

During  the  period  of  operation,  keep  the  subject  warm  by 
applying  a  proper  covering  and  by  laying  beside  his  body  bot- 
tles or  rubber  bags  filled  with  warm  (not  hot)  water.  The  at- 
tention to  keeping  the  subject  warm  should  be  given  by  an 
assistant  or  assistants. 

(8)  Do  not  give  any  liquids  whatever  by  mouth  until  the 
subject  is  fully  conscious. 

First  Care  of  Burns 

When  natural  respiration  has  been  restored,  burns,  if  seri- 
ous, should  be  attended  to  until  a  doctor  comes. 

A  raw  or  blistered  surface  should  be  protected  from  the 
air.  If  clothing  sticks,  do  not  peel  it  off — cut  around  it.  The 
adherent  cloth,  or  a  dressing  of  cotton  or  other  soft  material 
applied  to  the  burned  surface,  should  be  saturated  with  picrjc 
acid  (0.5  per  cent.).  If  this  is  not  at  hand,  use  a  solution  of 
baking  soda   (one  teaspoonful  to  a  pint  of  water),  or  the 


298  APPENDIX 

wound  may  be  coated  with  a  paste  of  flour  and  water.  Or  it 
may  be  protected  with  a  heavy  oil,  such  as  machine  oil,  trans- 
former oil,  vaselin,  linseed,  carron,  or  olive  oil.  Cover  the 
dressing  with  cotton,  gauze,  lint,  clean  waste,  clean  handker- 
chiefs, or  other  soft  cloth,  held  lightly  in  place  by  a  bandage. 

The  same  coverings  should  be  lightly  bandaged  over  a  dry, 
charred  burn,  but  without  wetting  the  burned  region  or  apply- 
ing oil  to  it. 

Do  not  open  blisters. 


INDEX 


Abdominal    aorta,    embolism    of,      Anemia,  cerebral,  ligation  of  ex 


cardinal  symptoms  of,  112 

cause  of,  109 

followed  by  ischemic  paraly- 
sis, 133 
occlusion  of,  108,  no 

diagnosis  of,  117 

establishment     of     collateral 
circulation  after,  108,  117 

followed   by   gangrene,    114, 

"5 

of  endovascular  origin,  no 

prognosis  of,  117 
treatment  of,  121,   122 
thrombosis    of,    symptoms    of, 

"3 

Adrenalin,      coronary      pressure 
raised  by,  239 
methods  of  using,  to  raise  cor- 
onary pressure,  239,  244 
resuscitation  by  means  of,  4 
Alcohol,  prevention  of  bed-sores 

with,  147 

Anatomy,    surgical,    of    vascular 

system  of  head  and  neck,  68 

Anemia,  cerebral,  3,  5,  55,  65,  72, 

242,  251 

anatomical       protection 

against,  8 
ligation   of   common   carotid 
arteries  as  a-  cause  of,  55, 
57 


ternal  carotid  artery,  effect 
of,  71 
limit  of  possible  duration  of 

life  with  total,  30,  53 
protection  against,  6 
temporary    closure    of    com- 
mon carotid,  effect  of,  65 
changes  due  to,  which  just  fall 

short  of  gangrene,  123 
changes  due  to,  of  the  kidney, 

210,  214 
complete,  with  complete  recov- 
ery,  143 
death  of  tissue  due  to,  145 
degrees  of,  produced  by  vascu- 
lar occlusion,   14 
effect  of  total,  on  kidneys,  198 
from  too  tightly  tied  stitches,  149 
fundamental  law  of,  114 
gangrene  caused  by,   115,   144, 

193 
infection  after,  251 
in  spinal  cord  lesions,  146 
intestinal,  150,  178,  179 

tabulation     of     experiments 

on,  177 
ischemic    contracture    due    to, 

133.  142 
local,  250 
muscular,       accompanied       by 

paralysis,  74 


299 


300 


INDEX 


Anemia,      muscular      contracture 
due  to,  134,  136,  137,  138, 

143 

of  central  nervous  system,  5,  8, 

55 
of  extremities  of  dogs,  73,  75, 

106 
of  kidney,    195,   196,   210,   212, 

214 
hemorrhage  in,  211 
of  lower   extremities   in   man, 

123 
of  skin,  147,  149,  250 
of  spinal  cord,  113,  146 
of  spleen,  214,  219 
of  voluntary  muscles,  j'i^,   100, 

123,  133 
paralysis      due      to,      73,      74, 

133 

partial,  with  complete  recov- 
ery, 143 

pressure  as  a  cause  of,  142, 
144,  149 

prevention  of  local  death  from, 
146 

recovery  results  after  varying 
periods  of,  13 

required  to  produce  dementia, 

14 

resistance  to,   145 

restoration  of  the  higher  fac- 
ulties after,  17,  18 

results  from,  105,  210,  250 

surgical,  71,  133 

total,  145,  147,  148 
Anesthesia,  effect  of,  on  recovery 
after     complete      cerebral 
anemia,  10 

resuscitation  of  animals  killed 
by,  54 
Arterial    injection    of    adrenalin, 


resuscitation  by  means  of, 

239 

Arteriosclerosis,  72,  124  . 
Artificial   respiration,   indications 
and  limitations  of,  241 
methods  for  producing,  222 
relative   efficiency    of   methods 

of,  223 
resuscitation   by   means    of,    9, 

221,  222,  229,  241,  243 
Schafer's  method  of,  22^^,  224, 

243 
without      movement      of      the 
thorax,  225 

Auditory  senses   after  resuscita- 
tion, 17,  25 

Author's  method  of  resuscitation, 
244 


Bed-sores,  alcohol  for  the  pre- 
vention of,  147 

cause  of,  146,  147 

low  blood-pressure  in  the  for- 
mation of,  147 

mechanism    of    formation    of, 

147 
prevention  of,  by  alcohol,  146, 

147 
Blood-pressure,  23,  72,   122,    148, 

219,  231,  238 
after    anemia    of    the    spleen, 

219 
after  resuscitation,  23,  52 
effect  of  simultaneous  closure 

of  both  carotid  arteries  on, 

effect  of  temporary  closure  of 

common  carotid  on,  65 
fall  of,_  from  anemia,  146,  147 
from  shock,   146 


INDEX 


301 


Blood-pressure,  increase  of,  in 
coronary  artery  as  means 
of  resuscitation,  238 
by  rhythmic  pressure  on  the 
thorax  as  means  of  resus- 
citation, 231 
intracerebral,    equalization    of, 

7 
Blood-supply,  of  brain,  6,  55 

occlusion   of,   by   ligation   of 
arteries,  56 
of  kidneys,  changes  due  to  oc- 
clusion of,  213,  214 
Brain,  anemia  of,  72 
blood-supply  of,  6,  55,  56 

Cardinal   symptoms  of  occlusion 

of  abdominal  aorta,  112 
Cerebral  anemia,  3,  5,  55,  58,  65, 
72,  242,  251 
anatomical   protection   against, 

8 
effect  of  temporary  closure  of 
common  carotid  artery  on, 

65 
ligation  of  common  carotid  as 

a  cause  of,  55,  57,  59 
limit    of    possible    duration    of 

life  with,  53,  242 
protection  against,  6 
Cerebral     circulation,     effect     of 

ligation       of       innominate 

artery  on,  56 
of  common  carotid  on,  56 
Cerebral    injury,    from   intestinal 

gangrene,  193 
from    ligation    of    the    carotid 

arteries,    57,    58,    59,    60, 

62 
from  temporary  closure  'of  the 

common  carotid,  ^y 


Chloroform,    danger    in   the    use 

of,  238 
Circle  of  Willis,  7,  55,  56,  (ij,  68, 

7^ 

Circulation,    cerebral,     effect    of 
ligation  of  common  carotid 
artery  on,  56 
effect  of  ligation  of  innomi- 
nate artery  on,  56 
collateral,      establishment      of, 
after  occlusion  of  abdomi- 
nal aorta,  108,  117 
in  kidneys   after  ligation  of 
the  renal  artery,  197 
effect  of  temporary  closure  of 

the  carotid  artery  on,  d^i 
in  kidneys,  195 

changes  due  to  occlusion  of, 
196 
Common    carotid    artery,    effects 
of   closure   of,   65,   6(i,   67, 

72 
ligation  of,  55,  56,  57,  59,  65, 

69,  70 
Common  femoral  artery,  ligation 

of,  123,  124,  127,  128 
Common  iliac  artery,  ligation  of, 

123,  125 
Coronary     pressure,     means     of 
raising,  238,  239 

Degeneration,    of    muscle    fibers 

due  to  anemia,  73,  105 
of  nerve  fibers,  ascending  and 

descending,  31 
in  pyramidal  fasciculi,  31 
Degrees  of  anemia  produced  by 

vascular   occlusions,   14 
Delirium  cordis,  230 
Dementia,  anemia  as  a  cause  of, 

14 


302 


INDEX 


Diag'nosis    of    occlusion    of    ab- 
dominal aorta,  117 

Edema   due   to   occlusion   of   ab- 
dominal aorta,  116 
Embolism,  causing  muscular  con- 
tracture, 135,  137 
from  ligation   of  the   common 

carotid,  59 
from  temporary  closure  of  the 
common  carotid  artery,  67 
of  the  abdominal  aorta,  112 

cause  of,  109 
of  the  brachial  artery,  135 
Esmarch  bandage,  75 
External  carotid   artery,  ligation 
of,  71 
temporary  closure  of,  (ij 
External  femoral  artery,  ligation 
of,  130 

Faculties,   slow   return   of,    after 
complete  anemia,  17,  18 

Flechsig's  fasciculus,  31 
Fractures,  treatment  of,  144,  145 
Fundamental  law  of  anemia,  114 

Gangrene  after  occlusion  of  the 
abdominal  aorta,  114 

cerebral     symptoms    in    death 
from,  193 

from  anemia,  144,  193 

from  ligation  of  common  iliac 
artery,  125 
of  external  iliac  artery,   126 
of   the    femoral    artery,    128, 
130 

from  saline  infusions,  148 

intestinal,    principle    in    opera- 
tions for,   193 

occurrence  of,  132,  134,  141, 
142 


Heart,  direct  massage  of,  4,   12, 
241,  242 
effect  of  electric  shock  on,  233 
reanimation  of,  227,  229,  242 
resuscitation  of,  233 
Hemorrhage,  control  of,  by  liga- 
tion of  arteries,  70 
from  anemia  of  the  spleen,  219 
in  kidney  anemia,  211 
ligation   of   iliac   artery   after, 

124,  127 
of    the    tonsils    and    pharynx, 
ligation  .of  arteries  for,  69 
Hemiplegia,     vascular     ligations 
followed  by,  56,  58,  59,  60, 
70  _ 
Hyperemia,  65,  113 
Hyperexcitability,    following    re- 
suscitation, 16,  29 
Hypertonicity    of    the    voluntary 
musculature,  15 

Iliac  artery,  ligation  of,  123,  125, 

126,  127 
Intestinal  anemia,  150,  178,  179 
tabulation    of   experiments   on, 

177 

Intestinal  gangrene,  principle  in 
operations   for,    193 

Intestinal  obstructions,  192 

Intracerebral  pressure,   equaliza- 
tion of,  7 

Ischemic    contracture,    cause    of, 
140,  141,  142 

Ischemic  paralysis,  133,  141 
caused  by  anemia,  133 

Kidney,  anemia  of,  195,  196,  210, 
212 
effect  of  total  anemia  on,  19S 
reimplantation  of,    195,    196 


INDEX 


303 


Ligation,  of  common  carotid  ar- 
tery, 55,  56,  57.  59.  65,  70 
cerebral  anemia  after,  55,  57, 

59 
cerebral  injury  after,  57,  59, 

60,  62 
embolism  after,  59 
injury  to  the  eyes  after,  62 
mortality  in  cases  of,  61 
technique  of,  65 
of  common  femoral  artery,  123, 

124,   127,   128 
of   common    iliac   artery,    123, 

125 
of  external  carotid  artery,  71 
of  external  femoral  artery,  130 
of   external    iliac   artery,    126, 

127 
of  external  iliac  arteries  simul- 
taneously, 127 
of     innominate     artery,     effect 
of,  on  cerebral  circulation, 

56 
of  main    arterial  trunks   as   a 

cause  of  anemia,  123 
of  main  artery  of  the  limb  as 

a  cause  of  gangrene,  134 
of   posterior   branch    of   renal 

artery,   197 
Limit,   of   resuscitation   in  cases 

of  drowning,  ^2 
of  total  cerebral  anemia,  53 

Methods     of     resuscitation,     au- 
thor's,  244 
of  heart,  234 
direct,  23 
intrathoracic,  234 
subdiaphragmatic,  234 
transdiaphragmatic,  234 
Schafer's,  223,  224,  243 


Micturition  and  defecation  after 

resuscitation,  25 
Muscular    anemia,    accompanied 
by  sensory  paralysis,  74 
functional   recovery   after,    74, 

105,  123 
paralysis  due  to,  105 
Muscular   contracture,   from   an- 
emia,   134,    136,    137,    138, 

143 
from  nerve  injury,  140,  143 
from  pressure,  138,  140,  143 
Muscular  movements,  during  re- 
suscitation    from    anemia, 

17 

reflex,  return  of,  after  recov- 
ery from  anemia,  15 

spontaneous  incoordinate,  after 
recovery  from  anemia,  15 

Necrosis,  aseptic,  147,  250 

of  cortex  from  ligation  of 
posterior  branch  of  renal 
artery,  197 

Occlusion,     degrees     of     anemia 
produced  by  vascular,  14 
of  abdominal  aorta  in  man,  108 

Olfactory   sense   after  resuscita- 
tion, 25 

Paralysis,   from  anemia,   y%   74, 

105,  133 
ischemic,    following    embolism 

of  abdominal  aorta,  133 
resulting  from  ligations,  63 
Paresthesia,  113,  114,  135 
Phonation,    return    of,    after    re- 
suscitation, 25 
Pott's  fracture,  141 


304 


INDEX 


Pyramidal  fasciculi,  fiber  degen- 
eration in,  due  to  anemia, 

31 


Raynaud's  disease,  117 
Reanimation  of  the  heart,  meth- 
ods of,  229,  242 
Recovery,  complete,  after  partial 
anemia,  143 
after  total  anemia,   143 
effect  of  anesthesia  on,  10 
functional,       after       muscular 
anemia,  74,  105,  123 
Recovery  experiments,  technique 

of,  10 
Recovery   results   after   complete 
anemia    for   varying   peri- 
ods, 13 
Reflex  muscular  movements,  15 
Reflexes,  return  of,  after  resus- 
citation, 24 
after  restoration  of  the  cir- 
culation, 53 
sequence  of  return  of,  after 
anemia,  15 
Respiration,   following  resuscita- 
tion, 20 
return   of,   as   result   of  direct 
massage  of  the  heart,  12 
Resuscitation,  251 

adrenalin-saline    infusion    for, 

241 
arterial  injection  of  adrenalin, 

as  means  of,  239 
artificial   respiration   as   means 

of,  4,  9,  221,  241 
author's  method  of,  244 
blood-pressure  after,  52 
by    adrenalin    in    saline    intra- 
vascular infusion,  4,  244 


Resuscitation   by   direct   massage 

of  the  heart,  4,  239,  242,  244 

by  injection  of  saline  solution, 

4 
by    rhythmic   pressure    on   the 

chest,  4 
over  the  heart,  9 
course  of  events  after,  16 
from  complete  anemia,  17 

muscular  movements  in,   17 
from    death   on   the   operating 

table,   245 
from  drowning,  ^2,  245  ' 
in  relative  death,  221 
of  animals  killed  by  anesthesia 

and  asphyxia,  9,  54 
of  a  body  as  a  whole,  4,  220, 

241 
methods  of,  241 
of  circulatory  apparatus,  226 
of  dogs  after  relative  death,  8, 

227 
of    heart,    by    direct    methods, 

233 

intrathoracic,  234 
subdiaphragmatic,  234 
transdiaphragmatic,  234 
by      electrical      stimulation, 
232 
of  electrocuted  dogs,  245 
of   respiratory   apparatus,  221, 

225 
raising     coronary     blood-pres- 
sure as  means  of,  238 
respiration  following,  20 
Schafer's  method  of,  223,  224, 

243 
special    phenomena    following, 
20 
Resuscitation    Committee,    Fifth, 
223 


INDEX 


305 


Saline  infusions,  sequence  of 
events  after  use  of,  148 

Saline  intravascular  infusion  as 
means  of  resuscitation,  4 

Schafer's  method  for  giving  arti- 
ficial respiration,  22^,  224, 

243 
Sensory  paralysis   accompanying 

muscular  anemia,  74 
Shock,  blood-pressure  in,  146 
Skin,  anemia  of,  147,  149,  250 
Spastic  condition  after  resuscita- 
tion   from    complete    ane- 
mia, 17 
Spinal  cord,  anemia  of,  113,  146 
Spleen,  anemia  of,  214,  219 


Temperature    following    resusci- 
tation from  anemia,  25 


Thrombus,      after      ligation      of 
carotid  arteries,   59,  60 
cause   of,   in   occlusion   of   ab- 
dominal aorta,  113 

Toxemia  from  gangrenous  intes- 
tine, 191,  192 

Traumatism,  ligation  of  common 
femoral  artery  after,  127, 
128 

Vascular    system    of    head    and 

neck,  surgical  anatomy  of, 

68 

Viability  of  vital  centers,  15 

Visual   reaction    in    resuscitation 

from  complete  anemia,  17, 

25 

Volhard  tube,  for  artificial  res- 
piration, 226 

V^olkmann-Leser  contracture,  133 


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